National trends in utilization 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.

National surveillance using a clinical quality indicator for prolonged antipsychotic use among older Australians with dementia who access aged care services.

OBJECTIVES: Dementia guidelines recommend antipsychotics are only used for behavioral and psychological symptoms when non-drug interventions fail, and to regularly review use. Population-level clinical quality indicators (CQIs) for dementia care in permanent residential aged care (PRAC) typically monitor prevalence of antipsychotic use but not prolonged use. This study aimed to develop a CQI for antipsychotic use >90 days and examine trends, associated factors, and variation in CQI incidence; and examine duration of the first episode of use among individuals with dementia accessing home care packages (HCPs) or PRAC. METHODS: Retrospective cohort study, including older individuals with dementia who accessed HCPs (n = 50,257) or PRAC (n = 250,196). Trends in annual CQI incidence (2011-12 to 2015-16) and associated factors were determined using Poisson regression. Funnel plots examined geographical and facility variation. Time to antipsychotic discontinuation was estimated among new antipsychotic users accessing HCP (n = 2367) and PRAC (n = 15,597) using the cumulative incidence function. RESULTS: Between 2011-12 and 2015-16, antipsychotic use for >90 days decreased in HCP recipients from 10.7% (95% CI 10.2-11.1) to 10.1% (95% CI 9.6-10.5, adjusted incidence rate ratio (aIRR) 0.97 (95% CI 0.95-0.98)), and in PRAC residents from 24.5% (95% CI 24.2-24.7) to 21.8% (95% CI 21.5-22.0, aIRR 0.97 (95% CI 0.96-0.98)). Prior antipsychotic use (both cohorts) and being male and greater socioeconomic disadvantage (PRAC cohort) were associated with higher CQI incidence. Little geographical/facility variation was observed. Median treatment duration in HCP and PRAC was 334 (interquartile range [IQR] 108-958) and 555 (IQR 197-1239) days, respectively. CONCLUSIONS: While small decreases in antipsychotic use >90 days were observed between 2011-12 and 2015-16, findings suggest antipsychotic use among aged care recipients with dementia can be further minimized.

Hospitalisations and emergency department presentations by older individuals accessing long-term aged care in Australia.

Objective The study examined emergency department (ED) presentations, unplanned hospitalisations and potentially preventable hospitalisations in older people receiving long-term care by type of care received (i.e. permanent residential aged care or home care packages in the community), in Australia in 2019. Methods A retrospective cohort study was conducted using the Registry of Senior Australians National Historical Cohort. Individuals were included if they resided in South Australia, Queensland, Victoria or New South Wales, received a home care package or permanent residential aged care in 2019 and were aged ≥65 years. The cumulative incidence of ED presentations, unplanned hospitalisations and potentially preventable hospitalisations in each of the long-term care service types were estimated during the year. Days in hospital per 1000 individuals were also calculated. Results The study included 203,278 individuals accessing permanent residential aged care (209,639 episodes) and 118,999 accessing home care packages in the community (127,893 episodes). A higher proportion of people accessing home care packages had an ED presentation (43.1% [95% confidence interval, 42.8-43.3], vs 37.8% [37.6-38.0]), unplanned hospitalisation (39.8% [39.6-40.1] vs 33.4% [33.2-33.6]) and potentially preventable hospitalisation (11.8% [11.6-12.0] vs 8.2% [8.1-8.4]) than people accessing permanent residential aged care. Individuals with home care packages had more days in hospital due to unplanned hospitalisations than those in residential care (7745 vs 3049 days/1000 individuals). Conclusions While a high proportion of older people in long-term care have ED presentations, unplanned hospitalisations and potentially preventable hospitalisations, people in the community with home care packages experience these events at a higher frequency.

Primary, allied health, selected specialists, and mental health service utilisation by home care recipients in Australia before and after accessing the care, 2017-2019.

OBJECTIVES: To examine changes in primary, allied health, selected specialists, and mental health service utilisation by older people in the year before and after accessing home care package (HCP) services. METHODS: A retrospective cohort study using the Registry of Senior Australians Historical National Cohort (≥ 65 years old), including individuals accessing HCP services between 2017 and 2019 (N = 109,558), was conducted. The utilisation of general practice (GP) attendances, health assessments, chronic disease management plans, allied health services, geriatric, pain, palliative, and mental health services, subsidised by the Australian Government Medicare Benefits Schedule, was assessed in the 12 months before and after HCP access, stratified by HCP level (1-2 vs. 3-4, i.e., lower vs. higher care needs). Relative changes in service utilisation 12 months before and after HCP access were estimated using adjusted risk ratios (aRR) from Generalised Estimating Equation Poisson models. RESULTS: Utilisation of health assessments (7-10.2%), chronic disease management plans (19.7-28.2%), and geriatric, pain, palliative, and mental health services (all ≤ 2.5%) remained low, before and after HCP access. Compared to 12 months prior to HCP access, 12 months after, GP after-hours attendances increased (HCP 1-2 from 6.95 to 7.5%, aRR = 1.07, 95% CI 1.03-1.11; HCP 3-4 from 7.76 to 9.32%, aRR = 1.20, 95%CI 1.13-1.28) and allied health services decreased (HCP 1-2 from 34.8 to 30.7%, aRR = 0.88, 95%CI 0.87-0.90; HCP levels 3-4 from 30.5 to 24.3%, aRR = 0.80, 95%CI 0.77-0.82). CONCLUSIONS: Most MBS subsidised preventive, management and specialist services are underutilised by older people, both before and after HCP access and small changes are observed after they access HCP.

Primary health care service utilisation before and after entry into long-term care in Australia.

OBJECTIVES: To examine utilisation of primary health care services (subsidised by the Australian Government, Medicare Benefits Schedule, MBS) before and after entry into long-term care (LTC) in Australia. METHODS: A retrospective cohort study of older people (aged ≥65 years) who entered LTC in Australia between 2012 and 2016 using the Historical Cohort of the Registry of Senior Australians. MBS-subsidised general attendances (general practitioner (GP), medical and nurse practitioners), health assessment and management plans, allied health, mental health services and selected specialist attendances accessed in 91-day periods 12 months before and after LTC entry were examined. Adjusted relative changes in utilisation 0-3 months before and after LTC entry were estimated using risk ratios (RR) calculated using Generalised Estimating Equation Poisson models. RESULTS: 235,217 residents were included in the study with a median age of 84 years (interquartile range 79-89) and 61.1% female. In the first 3 months following LTC entry, GP / medical practitioner attendances increased from 86.6% to 95.6% (aRR 1.10 95%CI 1.10-1.11), GP / medical practitioner urgent after hours (from 12.3% to 21.1%; aRR 1.72, 95%CI 1.70-1.74) and after-hours attendances (from 18.5% to 33.8%; aRR 1.83, 95%CI 1.81-1.84) increased almost two-fold. Pain, palliative and geriatric specialist medicine attendances were low in the 3 months prior (<3%) and decreased further following LTC admission. CONCLUSION: There is an opportunity to improve the utilisation of primary health care services following LTC entry to ensure that residents' increasingly complex care needs are adequately met.

The risk of fractures after entering long-term care facilities.

BACKGROUND: Stratifying residents at increased risk for fractures in long-term care facilities (LTCFs) can potentially improve awareness and facilitate the delivery of targeted interventions to reduce risk. Although several fracture risk assessment tools exist, most are not suitable for individuals entering LTCF. Moreover, existing tools do not examine risk profiles of individuals at key periods in their aged care journey, specifically at entry into LTCFs. PURPOSE: Our objectives were to identify fracture predictors, develop a fracture risk prognostic model for new LTCF residents and compare its performance to the Fracture Risk Assessment in Long term care (FRAiL) model using the Registry of Senior Australians (ROSA) Historical National Cohort, which contains integrated health and aged care information for individuals receiving long term care services. METHODS: Individuals aged ≥65 years old who entered 2079 facilities in three Australian states between 01/01/2009 and 31/12/2016 were examined. Fractures (any) within 365 days of LTCF entry were the outcome of interest. Individual, medication, health care, facility and system-related factors were examined as predictors. A fracture prognostic model was developed using elastic nets penalised regression and Fine-Gray models. Model discrimination was examined using area under the receiver operating characteristics curve (AUC) from the 20 % testing dataset. Model performance was compared to an existing risk model (i.e., FRAiL model). RESULTS: Of the 238,782 individuals studied, 62.3 % (N = 148,838) were women, 49.7 % (N = 118,598) had dementia and the median age was 84 (interquartile range 79-89). Within 365 days of LTCF entry, 7.2 % (N = 17,110) of individuals experienced a fracture. The strongest fracture predictors included: complex health care rating (no vs high care needs, sub-distribution hazard ratio (sHR) = 1.52, 95 % confidence interval (CI) 1.39-1.67), nutrition rating (moderate vs worst, sHR = 1.48, 95%CI 1.38-1.59), prior fractures (sHR ranging from 1.24 to 1.41 depending on fracture site/type), one year history of general practitioner attendances (≥16 attendances vs none, sHR = 1.35, 95%CI 1.18-1.54), use of dopa and dopa derivative antiparkinsonian medications (sHR = 1.28, 95%CI 1.19-1.38), history of osteoporosis (sHR = 1.22, 95%CI 1.16-1.27), dementia (sHR = 1.22, 95%CI 1.17-1.28) and falls (sHR = 1.21, 95%CI 1.17-1.25). The model AUC in the testing cohort was 0.62 (95%CI 0.61-0.63) and performed similar to the FRAiL model (AUC = 0.61, 95%CI 0.60-0.62). CONCLUSIONS: Critical information captured during transition into LTCF can be effectively leveraged to inform fracture risk profiling. New fracture predictors including complex health care needs, recent emergency department encounters, general practitioner and consultant physician attendances, were identified.

Clinical Quality Indicators for Monitoring Hospitalizations Among Older People with Dementia Accessing Aged Care Services.

BACKGROUND: There is a need for clinical quality indicators (CQIs) that can be applied to dementia quality registries to monitor care outcomes for people with Alzheimer's disease and other forms of dementia. OBJECTIVE: To develop tertiary and primary care-based dementia CQIs for application to clinical registries for individuals with dementia accessing aged care services and determine 1) annual trends in CQI incidence between 2011-2012 and 2015-2016, 2) associated factors, and 3) geographic and facility variation in CQI incidence. METHODS: This retrospective repeated cross-sectional study included non-Indigenous individuals aged 65-105 years who lived with dementia between July 2008-June 2016, were assessed for government-funded aged care services, and resided in New South Wales or Victoria (n = 180,675). Poisson or negative binomial regression models estimated trends in annual CQI incidence and associated factors. Funnel plots examined CQI variation. RESULTS: Between 2011-2012 and 2015-2016, CQI incidence increased for falls (11.0% to 13.9%, adjusted incidence rate ratio (aIRR) 1.05 (95% CI 1.01-1.06)) and delirium (4.7% to 6.7%, aIRR 1.09 (95% CI 1.07-1.10)), decreased for unplanned hospitalizations (28.7% to 27.9%, aIRR 0.99 (95% CI 0.98-0.99)) and remained steady for fracture (6.2% to 6.5%, aIRR 1.01 (95% CI 0.99-1.01)) and pressure injuries (0.5% to 0.4%, aIRR 0.99 (95% CI 0.96-1.02)). Being male, older, having more comorbidities and living in a major city were associated with higher CQI incidence. Considerable geographical and facility variation was observed for unplanned hospitalizations and delirium CQIs. CONCLUSIONS: The CQI results highlighted considerable morbidity. The CQIs tested should be considered for application in clinical quality registries to monitor dementia care quality.

Primary, allied health, geriatric, pain and palliative healthcare service utilisation by aged care residents, 2012-2017.

OBJECTIVES: To examine the incidence and trends in primary care, allied health, geriatric, pain and palliative care service use by permanent residential aged care (PRAC) residents and the older Australian population. METHODS: Repeated cross-sectional analyses on PRAC residents (N = 318,484) and the older (≥65 years) Australian population (N ~ 3.5 million). Outcomes were Medicare Benefits Schedule (MBS) subsidised primary care, allied health, geriatric, pain and palliative services between 2012-13 and 2016-17. GEE Poisson models estimated incidence rates and incidence rate ratios (IRR). RESULTS: In 2016-17, PRAC residents had a median of 13 (interquartile range [IQR] 5-19) regular general medical practitioner (GP) attendances, 3 (IQR 1-6) after-hours attendances and 5% saw a geriatrician. Highlights of utilisation changes from 2012-13 to 2016-17 include the following: GP attendances increased by 5%/year (IRR = 1.05, 95% confidence interval [CI] 1.05-1.05) for residents compared to 1%/year (IRR = 1.01, 95%CI 1.01-1.01) for the general population. GP after-hours attendances increased by 15%/year (IRR = 1.15, 95%CI 1.14-1.15) for residents and 9%/year (IRR = 1.08, 95%CI 1.07-1.20) for the general population. GP management plans increased by 12%/year (IRR = 1.12, 95%CI 1.11-1.12) for residents and 10%/year (IRR = 1.10, 95%CI 1.09-1.11) for the general population. Geriatrician consultations increased by 28%/year (IRR = 1.28, 95%CI 1.27-1.29) for residents compared to 14%/year (IRR = 1.14, 95%CI 1.14-1.15) in the general population. CONCLUSIONS: The utilisation of most examined services increased in both cohorts over time. Preventive and management care, by primary care and allied health care providers, was low and likely influences the utilisation of other attendances. PRAC residents' access to pain, palliative and geriatric medicine services is low and may not address the residents' needs.

Quality and safety in residential aged care: an evaluation of a national quality indicator programme.

BACKGROUND: In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities. AIM: To examine the validity of the QI programme indicators using explicit measure review criteria. METHODS: The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme's eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1-3 was considered to not meet criteria, 4-6 to meet some criteria and 7-9 to meet criteria. RESULTS: All indicators, except polypharmacy, met criteria (median scores = 7-9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2-8), appropriateness (median = 5, range 2-8) and clinical evidence (median = 6, range 3-8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6-7, range 4-8) and met criteria for feasibility and applicability (median = 7, range 4-8). CONCLUSIONS: Australia's National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures' specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.

Feasibility and validity of using healthcare databases to conduct cross-national comparative studies of opioid use, its determinants and consequences.

PURPOSE: A cross-national comparative (CNC) study about opioid utilization would allow the identification of strategies to improve pain management and mitigate risk. However, little is known about the accessibility and validity of information in healthcare databases internationally. This study aimed to identify the feasibility of using healthcare databases to conduct a CNC study of opioid utilization and its associated consequences. METHODS: A cross-sectional survey was launched in March 2018, including experts interested in CNC studies comparing opioid utilization by purposeful sampling. An electronic survey was used to collect database characteristics, medicine information, and linkage information of each aggregate-level dataset (AD) and individual patient-level dataset (IPD). RESULTS: Overall, participants from 21 geographical regions reported 18 ADs and 19 IPDs. Information on dispensed medications is available from 17 ADs and 17 IPDs. Of the 16 ADs that include primary care settings, only 9 ADs can obtain information from secondary care settings. Fourteen IPDs included patients' characteristics or could be retrieved from linkage databases. Although most ADs are publicly accessible (n = 13), only five IPDs can be accessed without extra cost. CONCLUSION: Most ADs could be used to report opioid utilization in a primary care setting. IPDs with linkage databases should be applied to identify potential determinants, clinical outcomes, and policy impact. Data access restrictions and governance policies across jurisdictions can be challenging for timely analysis and require further collaboration.

Death by suicide among aged care recipients in Australia 2008-2017.

OBJECTIVE: To characterize the features of aged care users who died by suicide and examine the use of mental health services and psychopharmacotherapy in the year before death. DESIGN: Population-based, retrospective exploratory study. SETTING AND PARTICIPANTS: Individuals who died while accessing or waiting for permanent residential aged care (PRAC) or home care packages in Australia between 2008 and 2017. MEASUREMENTS: Linked datasets describing aged care use, date and cause of death, health care use, medication use, and state-based hospital data collections. RESULTS: Of 532,507 people who died, 354 (0.07%) died by suicide, including 81 receiving a home care package (0.17% of all home care package deaths), 129 in PRAC (0.03% of all deaths in PRAC), and 144 approved for but awaiting care (0.23% of all deaths while awaiting care). Factors associated with death by suicide compared to death by another cause were male sex, having a mental health condition, not having dementia, less frailty, and a hospitalization for self-injury in the year before death. Among those who were awaiting care, being born outside Australia, living alone, and not having a carer were associated with death by suicide. Those who died by suicide more often accessed Government-subsidized mental health services in the year before their death than those who died by another cause. CONCLUSIONS: Older men, those with diagnosed mental health conditions, those living alone and without an informal carer, and those hospitalized for self-injury are key targets for suicide prevention efforts.

Development of a Multivariable Prediction Model for Risk of Hospitalization With Pressure Injury After Entering Residential Aged Care.

OBJECTIVES: Although largely preventable, pressure injury is a major concern in individuals in permanent residential aged care (PRAC). Our study aimed to identify predictors and develop a prognostic model for risk of hospitalization with pressure injury (PI) using integrated Australian aged and health care data. DESIGN: National retrospective cohort study. SETTING AND PARTICIPANTS: Individuals ≥65 years old (N = 206,540) who entered 1797 PRAC facilities between January 1, 2009, and December 31, 2016. METHODS: PI, ascertained from hospitalization records, within 365 days of PRAC entry was the outcome of interest. Individual, medication, facility, system, and health care-related factors were examined as predictors. Prognostic models were developed using elastic nets penalized regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination out-of-sample. RESULTS: Within 365 days of PRAC entry, 4.3% (n = 8802) of individuals had a hospitalization with PI. The strongest predictors for PI risk include history of PIs [sub-distribution hazard ratio (sHR) 2.41; 95% CI 1.77-3.29]; numbers of prior hospitalizations (having ≥5 hospitalizations, sHR 1.95; 95% CI 1.74-2.19); history of traumatic amputation of toe, ankle, foot and leg (sHR 1.72; 95% CI 1.44-2.05); and history of skin disease (sHR 1.54; 95% CI 1.45-1.65). Lower care needs at PRAC entry with respect to mobility, complex health care, and medication assistance were associated with lower risk of PI. The risk prediction model had an AUC of 0.74 (95% CI 0.72-0.75). CONCLUSIONS AND IMPLICATIONS: Our prognostic model for risk of hospitalization with PI performed moderately well and can be used by health and aged care providers to implement risk-based prevention plans at PRAC entry.

Aged and Health Care Service Utilization by Older Australians Receiving Home Care Packages.

OBJECTIVES: To examine the (1) cohort of individuals living at home with Home Care Packages (HCPs) in 2016, (2) their access to other aged care services after HCP commencement, and (3) their hospital and ambulance service utilization. DESIGN: A cross-sectional study was conducted using integrated aged care and health care data contained within the National Historical Cohort of the Registry of Senior Australians. SETTING AND PARTICIPANTS: This study included people who accessed HCP between January 1, 2016 and December 31, 2016. METHODS: The access to permanent residential aged care, transition care, respite care, hospital and ambulance services among Australian HCP recipients ≥65 years old in 2016 was evaluated. Descriptive statistics were employed. RESULTS: In 2016, 84,681 individuals received HCPs, of which 68.4% (n = 57,942) accessed HCP levels 1‒2, 26.0% (n = 22,057) accessed HCP levels 3‒4, and 5.5% (n = 4682) accessed both care levels within the year. Of the individuals receiving HCP, 34.0% (n = 27,787) started services that year and 16.7% (n = 14,117) moved to permanent residential aged care, 18.4% (n = 15,592) used respite care and 5.8% (n = 4937) used transition care that year. Emergency department (ED) presentations [43.6%, 95% confidence interval (CI) 43.3‒44.0] were the most common hospital encounters, followed by inpatient hospitalizations for any reason (43.3%, 95% CI 42.9‒43.7), and unplanned hospitalizations (38%, 95% CI 37.6‒38.3). Forty-four percent (44.5%, 95% CI 43.9‒45.0) of individuals utilized ambulance services. ED presentations, hospitalization for any reason, and unplanned hospitalizations were more common in individuals receiving HCP levels 3‒4 compared with those accessing HCP levels 1‒2. CONCLUSIONS AND IMPLICATIONS: HCP recipients in Australia have frequent hospitalizations, including ED presentations. In addition, almost 1 in 5 access respite care and 16.7% transition to permanent residential care each year. As the population accessing HCP is increasing, adequate support for these individuals to live well at home and avoid health events that lead to hospitalizations are necessary.

Trends in mental health service utilisation by Australia's older population.

OBJECTIVES: To examine the incidence, trends, and differences between age groups and sex in Medicare Benefits Schedule (MBS)-subsidised mental health service utilisation by older Australians over the past 10 years. METHODS: A cross-sectional cohort study between 1 July 2009 and 30 June 2019 was conducted using publicly available MBS data for older individuals aged ≥65 years. Age- and sex-standardised yearly incidence rates of psychological therapy (MBS M06), GP mental health treatments (MBS A20), focussed psychological strategy (MBS M07), and psychiatric attendances (MBS A08) and incidence rate ratios (IRR) estimated using Poisson regression were calculated. RESULTS: Overall, the rate of utilisation of primary care mental health services by the older population increased over the study period, with psychological therapy claims increasing the greatest from 14.4/1000 older persons in 2009/10 to 38.5/1000 in 2018/19 (IRR 1.11, 95% CI 1.09-1.13), followed by GP mental health treatments increasing from 43.7/1000 (95% CI 43.4-43.9) in 2009/10 to 81.0/1000 (95% CI 80.7-81.3) in 2018/19 (IRR 1.07/year, 95% CI 1.06-1.09). Females aged 65-74 years had the highest use of GP mental health treatments at 123.8/1000 compared to 63.6/1000 in males in 2018/2019. CONCLUSIONS: While utilisation of mental health services by the older population in Australia has increased over the study period, it is important that policymakers and service providers continue to support access and use of these services, which may facilitate well-being and quality of life in the older population.

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study.

BACKGROUND: no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality. OBJECTIVE: to examine associations between RMMR provision in the 6-12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs. DESIGN: retrospective cohort study. SUBJECTS: individuals aged 65-105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719). METHODS: Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation. RESULTS: there were 12,603 (21.8%) individuals who received an RMMR within 6-12 months of RACF entry, of whom 22.2% (95%CI 21.4-22.9) died during follow-up, compared with 23.3% (95%CI 22.9-23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91-0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls. CONCLUSIONS: provision of an RMMR in the 6-12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.

Primary and Secondary Care Related Quality Indicators for Dementia Care Among Australian Aged Care Users: National Trends, Risk Factors, and Variation.

BACKGROUND: Studies related to clinical quality indicators (CQIs) in dementia have focused on hospitalizations, medication management, and safety. Less attention has been paid to indicators related to primary and secondary care. OBJECTIVE: To evaluate the incidence of primary and secondary care CQIs for Australians with dementia using government-subsidized aged care. The examined CQIs were: comprehensive medication reviews, 75+ health assessments, comprehensive geriatric assessments, chronic disease management plans, general practitioner (GP) mental health treatment plans, and psychiatrist attendances. METHODS: Retrospective cohort study (2011-2016) of 255,458 individuals. National trend analyses estimated incidence rates and 95% confidence intervals (CI) using Poisson or negative binomial regression. Associations were assessed using backward stepwise multivariate Poisson or negative binomial regression model, as appropriate. Funnel plots examined geographic and permanent residential aged care (PRAC) facility variation. RESULTS: CQI incidence increased in all CQIs but medication reviews. For the overall cohort, 75+ health assessments increased from 1.07/1000 person-days to 1.16/1000 person-days (adjusted incidence rate ratio (aIRR) = 1.03, 95% CI 1.02-1.03).Comprehensive geriatric assessments increased from 0.24 to 0.37/1000 person-days (aIRR = 1.12, 95% CI 1.10-1.14). GP mental health treatment plans increased from 0.04 to 0.07/1000 person-days (aIRR = 1.13, 95% CI 1.12-1.15). Psychiatric attendances increased from 0.09 to 0.11/1000 person-days (aIRR = 1.05, 95% CI 1.03-1.07). Being female, older, having fewer comorbidities, and living outside a major city were associated with lower likelihood of using the services. Large geographical and PRAC facility variation was observed (0-92%). CONCLUSION: Better use of primary and secondary care services to address needs of individuals with dementia is urgently needed.

Impact of relational continuity of primary care in aged care: a systematic review.

BACKGROUND: Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes. METHODS: Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions. RESULTS: Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92-0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76-1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89-0.92, n = 178,686; IRR 0.91, 95%CI 0.72-1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners' visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335). CONCLUSION: Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed. REVIEW REGISTRATION: CRD42021215698.