Caregiver-reported use of physical restraints among community-dwelling older adults with severe dementia in Singapore.

BACKGROUND: Older adults with severe dementia are at increased risk of being physically restrained in nursing homes and acute care settings, but little is known about restraint use among those cared for at home. This study explores caregiver-reported use of restraints among community-dwelling older adults with severe dementia. METHODS: Using cross-sectional data from 215 family caregivers, we describe restraint use among older adults with severe dementia living at home. We then use multivariable logistic regression to identify factors associated with restraint use. RESULTS: Nearly half (47%) of caregivers reported on older adults who had been subject to restraints. Most caregivers reporting restraint use suggested safety reasons, such as prevention of falls (68%), wandering (30%), and removal of catheters or feeding tubes (29%); and 44% indicated doctors or other health care providers were involved in the decision to restrain. Feeding tubes (OR = 4.16, 95% CI: 1.27-13.59) and physically aggressive agitation behaviors (OR = 1.93, 95% CI: 1.09-3.40) were associated with higher odds of restraint use among older adults with severe dementia. Caregivers who received strong emotional support from friends (OR = 0.45, 95% CI: 0.21-0.95) were less likely to report restraint use while serving as a caregiver to others (OR = 2.77, 95% CI: 1.36-5.63) increased the odds of restraint use. CONCLUSIONS: The pervasiveness of restraint use is concerning and suggests a lack of evidence-based guidance and support for both caregivers and healthcare providers to prevent restraint use among older adults with severe dementia cared for at home.

Weak grip strength predicts higher unplanned healthcare utilization among patients with heart failure.

AIMS: Frailty increases healthcare utilization and costs for patients with heart failure but is challenging to assess in clinical settings. Hand grip strength (GS) is a single-item measure of frailty yet lacks evidence as a potential screening tool to identify patients at risk of higher unplanned events and related healthcare costs. We examined the association of baseline and longitudinal GS measurements with healthcare utilization and costs among patients with advanced heart failure. METHODS AND RESULTS: Between July 2017 and April 2019, we enrolled 251 patients with symptoms of advanced heart failure (New York Heart Association class III or IV) in a prospective cohort study in Singapore. We measured GS at baseline and every 4 months for 2 years and linked patients' survey data with their medical and billing records. We categorized patients as having weak GS if their GS measurement was below the 5th percentile of the age- and gender-specific normative GS values in Singapore. We assessed the association between baseline GS and healthcare utilization (unplanned and planned events and healthcare costs, total costs, and length of inpatient stay) over the next 2 years using regression models. We investigated the association between longitudinal 4-monthly GS assessments and the ensuing 4 months of healthcare utilization and costs using mixed-effects logistic and two-part regression models. At baseline, 22.5% of patients had weak GS. Baseline and longitudinal GS measurements were significantly associated with longer length of inpatient stay, greater likelihood of unplanned events, and higher related costs. Patients with weak GS had higher odds of an unplanned event occurring by 8 percentage points [95% confidence interval (CI) (0.01, 0.14), P = 0.026], incurred longer inpatient stays by 4 days [95% CI (1.97, 6.79), P = 0.003], and additional SG$ 4792 [US$ ~ 3594, 95% CI (1894, 7689), P = 0.014] in unplanned healthcare costs over the next 4 months. CONCLUSIONS: GS is a simple tool to identify and monitor heart failure patients at risk of unplanned events, longer inpatient stays, and higher related healthcare costs. Findings support its routine use in clinical settings.

Health conditions, payments, proximity, and opportunity costs: Examining delays in seeking inpatient and outpatient care in the Philippines.

Like other developing countries, the Philippines commits to achieving universal health coverage. To identify the factors - including health care needs, financial and physical access, and opportunity costs - associated with delays in seeking outpatient (OP) and inpatient (IP) care among household members with illness, injury or advised by a doctor, this paper estimates Cox and Weibull proportional hazard models using a nationally-representative sample of households surveyed in 2011, when the Philippine government just started implementing major health reforms. Our results indicate that the delays in seeking OP care tend to be shorter for the very young (5 years old or below), the elderly (65 years old or above), and those with prior poor health. Similarly, delays in seeking IP care tend to be shorter among the very young and those requiring maternity services. Moreover, having a college-educated head of household is associated with shorter delays in seeking OP and IP care. Delays in seeking OP care are shorter in the National Capital Region than in other regions, but longer OP delays are associated with presence of a nearby public health facility. Deferrals in seeking IP care are shorter and delays in seeking OP care are longer when the sick or injured member is employed. When the spouse of the household head is employed, IP care is likewise postponed further. Relative to the poorest income quintile, the second- and third-income quintiles tarry longer. Last, insurance coverage and urban location are not found to be significant correlates. To enhance the effectiveness of recent reforms on utilization, these results suggest deepening the awareness of the covered population of their insurance benefits or to monitor the quality of local health facilities, especially that received grants. Labor policies that reduce the opportunity cost of seeking care among the employed may also be considered.