Excess mortality among older adults institutionalized in long-term care facilities during the COVID-19 pandemic: a population-based analysis in Catalonia.

Objectives: To assess excess mortality among older adults institutionalized in nursing homes within the successive waves of the COVID-19 pandemic in Catalonia (north-east Spain). Design: Observational, retrospective analysis of population-based central healthcare registries. Setting and participants: Individuals aged >65 years admitted in any nursing home in Catalonia between January 1, 2015, and April 1, 2022. Methods: Deaths reported during the pre-pandemic period (2015-2019) were used to build a reference model for mortality trends (a Poisson model, due to the event counting nature of the variable "mortality"), adjusted by age, sex, and clinical complexity, defined according to the adjusted morbidity groups. Excess mortality was estimated by comparing the observed and model-based expected mortality during the pandemic period (2020-2022). Besides the crude excess mortality, we estimated the standardized mortality rate (SMR) as the ratio of weekly deaths' number observed to the expected deaths' number over the same period. Results: The analysis included 175,497 older adults institutionalized (mean 262 days, SD 132), yielding a total of 394,134 person-years: 288,948 person-years within the reference period (2015-2019) and 105,186 within the COVID-19 period (2020-2022). Excess number of deaths in this population was 5,403 in the first wave and 1,313, 111, -182, 498, and 329 in the successive waves. The first wave on March 2020 showed the highest SMR (2.50; 95% CI 2.45-2.56). The corresponding SMR for the 2nd to 6th waves were 1.31 (1.27-1.34), 1.03 (1.00-1.07), 0.93 (0.89-0.97), 1.13 (1.10-1.17), and 1.07 (1.04-1.09). The number of excess deaths following the first wave ranged from 1,313 (2nd wave) to -182 (4th wave). Excess mortality showed similar trends for men and women. Older adults and those with higher comorbidity burden account for higher number of deaths, albeit lower SMRs. Conclusion: Excess mortality analysis suggest a higher death toll of the COVID-19 crisis in nursing homes than in other settings. Although crude mortality rates were far higher among older adults and those at higher health risk, younger individuals showed persistently higher SMR, indicating an important death toll of the COVID-19 in these groups of people.

Prevention of Unplanned Hospital Admissions in Multimorbid Patients Using Computational Modeling: Observational Retrospective Cohort Study.

BACKGROUND: Enhanced management of multimorbidity constitutes a major clinical challenge. Multimorbidity shows well-established causal relationships with the high use of health care resources and, specifically, with unplanned hospital admissions. Enhanced patient stratification is vital for achieving effectiveness through personalized postdischarge service selection. OBJECTIVE: The study has a 2-fold aim: (1) generation and assessment of predictive models of mortality and readmission at 90 days after discharge; and (2) characterization of patients' profiles for personalized service selection purposes. METHODS: Gradient boosting techniques were used to generate predictive models based on multisource data (registries, clinical/functional and social support) from 761 nonsurgical patients admitted in a tertiary hospital over 12 months (October 2017 to November 2018). K-means clustering was used to characterize patient profiles. RESULTS: Performance (area under the receiver operating characteristic curve, sensitivity, and specificity) of the predictive models was 0.82, 0.78, and 0.70 and 0.72, 0.70, and 0.63 for mortality and readmissions, respectively. A total of 4 patients' profiles were identified. In brief, the reference patients (cluster 1; 281/761, 36.9%), 53.7% (151/281) men and mean age of 71 (SD 16) years, showed 3.6% (10/281) mortality and 15.7% (44/281) readmissions at 90 days following discharge. The unhealthy lifestyle habit profile (cluster 2; 179/761, 23.5%) predominantly comprised males (137/179, 76.5%) with similar age, mean 70 (SD 13) years, but showed slightly higher mortality (10/179, 5.6%) and markedly higher readmission rate (49/179, 27.4%). Patients in the frailty profile (cluster 3; 152/761, 19.9%) were older (mean 81 years, SD 13 years) and predominantly female (63/152, 41.4%, males). They showed medical complexity with a high level of social vulnerability and the highest mortality rate (23/152, 15.1%), but with a similar hospitalization rate (39/152, 25.7%) compared with cluster 2. Finally, the medical complexity profile (cluster 4; 149/761, 19.6%), mean age 83 (SD 9) years, 55.7% (83/149) males, showed the highest clinical complexity resulting in 12.8% (19/149) mortality and the highest readmission rate (56/149, 37.6%). CONCLUSIONS: The results indicated the potential to predict mortality and morbidity-related adverse events leading to unplanned hospital readmissions. The resulting patient profiles fostered recommendations for personalized service selection with the capacity for value generation.

Reply to Inzitari et al. Comment on "Blancafort Alias et al. A Multi-Domain Group-Based Intervention to Promote Physical Activity, Healthy Nutrition, and Psychological Wellbeing in Older People with Losses in Intrinsic Capacity: AMICOPE Development Study. Int. J. Environ. Res. Public Health 2021, 18, 5979".

This is a reply to the comment by Inzitari et al [...].

A Multi-Domain Group-Based Intervention to Promote Physical Activity, Healthy Nutrition, and Psychological Wellbeing in Older People with Losses in Intrinsic Capacity: AMICOPE Development Study.

The World Health Organization has developed the Integrated Care of Older People (ICOPE) strategy, a program based on the measurement of intrinsic capacity (IC) as "the composite of all physical and mental attributes on which an individual can draw". Multicomponent interventions appear to be the most effective approach to enhance IC and to prevent frailty and disability since adapted physical activity is the preventive intervention that has shown the most evidence in the treatment of frailty and risk of falls. Our paper describes the development of a multi-domain group-based intervention addressed to older people living in the community, aimed at improving and/or maintaining intrinsic capacity by means of promoting physical activity, healthy nutrition, and psychological wellbeing in older people. The process of intervention development is described following the Guidance for reporting intervention development studies in health research (GUIDED). The result of this study is the AMICOPE intervention (Aptitude Multi-domain group-based intervention to improve and/or maintain IC in Older PEople) built upon the ICOPE framework and described following the Template for Intervention Description and Replication (TIDieR) guidelines. The intervention consists of 12 face-to-face sessions held weekly for 2.5 h over three months and facilitated by a pair of health and social care professionals. This study represents the first stage of the UK Medical Research Council framework for developing and evaluating a complex intervention. The next step should be carrying out a feasibility study for the AMICOPE intervention and, at a later stage, assessing the effectiveness in a randomized controlled trial.

Determinants of the number of days people in the general population spent at home during end-of-life: Results from a population-based cohort analysis.

BACKGROUND: The number of days spent at home in the last six months of life has been proposed as a comprehensive indicator of high-value patient-centered care; however, information regarding the determinants of this outcome is scarce, particularly among the general population. We investigated the determinants of spending time at home within the six months preceding death. METHODS: Population-based, retrospective analysis of administrative databases of the Catalan government. The analysis included adult (≥18 years) individuals who died in Catalonia (North-east Spain) in 2017 and met the McNamara criteria for palliative care. The primary outcome was the number of days spent at home within the last 180 days of life. Other variables included the cause of death, demographic characteristics, and socioeconomic status, stratified as very low, low, mid, and high level. RESULTS: The analysis included 40,137 individuals (19,510 women; 20,627 men), who spent a median of 140 days (IQR 16-171) at home within the six months preceding death (women 140 [16-171]; men 150 [100-171]). Female gender was an independent factor of staying fewer days at home (OR 0.80 [95% CI 0.77-0.82]; p<0.001). Higher socioeconomic levels were significantly associated with an increasing number of days at home in both genders: among women, ORs of the low, middle, and high levels were 1.09 (0.97-1.22), 1.54 (1.36-1.75), and 2.52 (1.69-3.75) (p<0.001), respectively; the corresponding ORs among men were 1.27 (1.12-1.43), 1.56 (1.38-1.77), 2.82 (2.04-3.88) (p<0.001). The presence of dementia was a strong predictor of spending less time at home in women (0.41 (0.38-0.43); p<0.001) and men (0.45 (0.41-0.48); p<0.001). CONCLUSIONS: Our results suggest that end-of-life care is associated with gender and socioeconomic inequalities; women and individuals with lower socioeconomic status spend less time at home within the last 180 days of life.

VIG-Express: Consenso de un sistema de valoración multidimensional/geriátrica rápida en Cataluña / VIG-Express: Consensus on an express multidimensional/geriatric assessment system in Catalonia

Objetivo: Consensuar una herramienta de valoración multidimensional/geriátrica rápida (VMGR), como sistema compartido y universal de valoración multidimensional de personas con multimorbilidad, fragilidad, complejidad o situación avanzada, para todos los profesionales del sistema de salud y social de Cataluña. Diseño: Consenso de profesionales en tres fases, combinando sesiones presenciales con trabajo telemático. Emplazamiento: Cataluña. Participantes: Se constituyó un grupo de 27 profesionales de carácter interdisciplinario representativo de los distintos ámbitos de atención. Método: Se han combinado las metodologías de Design thinking para el consenso inicial de características de la herramienta de VMGR (fase 1), con la metodología Lean Start-Up para el diseño de la nueva herramienta de VMGR (fase 2), que finalmente se testeó en un grupo de pacientes (fase 3). Resultados: En la fase 1 se consensuó que la herramienta de VMGR ideal debía permitir una valoración ad hoc de las personas, ser rápida y ágil (tiempo < 10 minutos), identificar las dimensiones alteradas mediante preguntas trigger y facilitar el diagnóstico de situación (idealmente cuantificado). En la fase 2 se elaboró el prototipo de una nueva herramienta de VMGR de 15 + dos preguntas (VIG-Express), finalmente testeada en 35 personas en la fase 3. Conclusiones: En los resultados preliminares, la herramienta VIG-Express parece facilitar una valoración multidimensional sencilla y rápida y la personalización de las intervenciones, así como una mirada única y un relato compartido entre los profesionales de los distintos ámbitos de atención. Serán necesarios más estudios para corroborar estos hallazgos.(AU)

Objective: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. Design: Three-phase consensus of professionals, combining in-person sessions with telematics. Location: Catalonia. Participants: A group of 27 interdisciplinary professionals from different care settings. Method: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). Results: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (<10 min), identify altered dimensions using trigger questions and facilitate the diagnosis of the condition (ideally quantified). In Phase 2, a prototype of a new RMGA tool containing 15 + 2 questions (VIG-Express) was developed, which was then tested in 35 patients in Phase 3. Conclusions: Based on preliminary results, the VIG-Express tool seems to facilitate a simple, rapid multidimensional assessment and the customization of interventions, as well as provide a unique look and shared narrative between professionals from different care settings. More studies will be required to corroborate these findings.(AU)

[VIG-Express: Consensus on an express multidimensional/geriatric assessment system in Catalonia]. / VIG-Express: Consenso de un sistema de valoración multidimensional/geriátrica rápida en Cataluña.

OBJECTIVE: To reach a consensus on an rapid multidimensional/geriatric assessment (RMGA) tool for all health and social professionals of Catalonia as a shared and universal system to assess patients with multimorbidities, frailty, complexity or advanced conditions. DESIGN: Three-phase consensus of professionals, combining in-person sessions with telematics. LOCATION: Catalonia. PARTICIPANTS: A group of 27 interdisciplinary professionals from different care settings. METHOD: The Design Thinking methodology for an initial consensus on the characteristics of the RMGA tool (Phase 1) has been combined with the Lean Startup methodology to create a new RMGA tool (Phase 2), and then tested in a group of patients (Phase 3). RESULTS: In Phase 1, a consensus was reached that the perfect RMGA tool should allow for an ad hoc assessment of patients, be fast and flexible (<10 min), identify altered dimensions using trigger questions and facilitate the diagnosis of the condition (ideally quantified). In Phase 2, a prototype of a new RMGA tool containing 15 + 2 questions (VIG-Express) was developed, which was then tested in 35 patients in Phase 3. CONCLUSIONS: Based on preliminary results, the VIG-Express tool seems to facilitate a simple, rapid multidimensional assessment and the customization of interventions, as well as provide a unique look and shared narrative between professionals from different care settings. More studies will be required to corroborate these findings.

Mapping variability in allocation of Long-Term Care funds across payer agencies in OECD countries.

INTRODUCTION: Long-term care (LTC) is organized in a fragmented manner. Payer agencies (PA) receive LTC funds from the agency collecting funds, and commission services. Yet, distributional equity (DE) across PAs, a precondition to geographical equity of access to LTC, has received limited attention. We conceptualize that LTC systems promote DE when they are designed to set eligibility criteria nationally (vs. locally); and to distribute funds among PAs based on needs-formula (vs. past-budgets or government decisions). OBJECTIVES: This cross-country study highlights to what extent different LTC systems are designed to promote DE across PAs, and the parameters used in allocation formulae. METHODS: Qualitative data were collected through a questionnaire filled by experts from 17 OECD countries. RESULTS: 11 out of 25 LTC systems analyzed, fully meet DE as we defined. 5 systems which give high autonomy to PAs have designs with low levels of DE; while nine systems partially promote DE. Allocation formulae vary in their complexity as some systems use simple demographic parameters while others apply socio-economic status, disability, and LTC cost variations. DISCUSSION AND CONCLUSIONS: A minority of LTC systems fully meet DE, which is only one of the criteria in allocation of LTC resources. Some systems prefer local priority-setting and governance over DE. Countries that value DE should harmonize the eligibility criteria at the national level and allocate funds according to needs across regions.

Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols.

BACKGROUND: Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016-2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011-2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). METHODS: The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. DISCUSSION: The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. TRIALS REGISTRATION: NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018).

The Measure of the Family Caregivers' Experience.

Objective: Design and validate a measure of the experience of family caregivers with the integrated care that receive the persons they care for. Methods: The new instrument for measuring the experience of caregivers is based on the Instrument to Evaluate the EXperience of PAtients with Chronic Diseases (acronym in Spanish: IEXPAC) scale instrument. With the qualitative technique of the discussion group, nine professionals and eight caregivers assessed the face validity of the instrument and they advised on issues to explore and the measuring scale to use. The instrument's items were analyzed individually, as well as its consistency, reliability, and construct and empirical validity. Results: 235 caregivers responded, of which 186 (79%) were women. The average age of the persons under their care was 83.9 years (SD 9.7). The scale's score when eliminating its items one by one ranged between 38.6 and 41.1. The factorial saturations of the items ranged between 0.53 and 0.82. Cronbach's alpha (12 elements) was 0.88 and the Kuder-Richardson coefficient was 0.91. The factorial solution explained 64.3% of the total variance and allowed isolating two factors (with 11 items with saturations greater than 0.65): care for the patient, and care for the caregiver. The internal consistency of both factors was greater than 0.80. The scale's score was 41.1 (SD 9.7). Conclusions: The Caregivers Experience Instrument combines acceptability, ease of comprehension, and perceived usefulness for the caregivers. It has adequate internal consistency, reliability, and construct and empirical validity.

La atención integrada y el reto de la cronicidad / Integrated care and the challenge of chronic illness

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Proposals for enhanced health risk assessment and stratification in an integrated care scenario.

OBJECTIVES: Population-based health risk assessment and stratification are considered highly relevant for large-scale implementation of integrated care by facilitating services design and case identification. The principal objective of the study was to analyse five health-risk assessment strategies and health indicators used in the five regions participating in the Advancing Care Coordination and Telehealth Deployment (ACT) programme (http://www.act-programme.eu). The second purpose was to elaborate on strategies toward enhanced health risk predictive modelling in the clinical scenario. SETTINGS: The five ACT regions: Scotland (UK), Basque Country (ES), Catalonia (ES), Lombardy (I) and Groningen (NL). PARTICIPANTS: Responsible teams for regional data management in the five ACT regions. PRIMARY AND SECONDARY OUTCOME MEASURES: We characterised and compared risk assessment strategies among ACT regions by analysing operational health risk predictive modelling tools for population-based stratification, as well as available health indicators at regional level. The analysis of the risk assessment tool deployed in Catalonia in 2015 (GMAs, Adjusted Morbidity Groups) was used as a basis to propose how population-based analytics could contribute to clinical risk prediction. RESULTS: There was consensus on the need for a population health approach to generate health risk predictive modelling. However, this strategy was fully in place only in two ACT regions: Basque Country and Catalonia. We found marked differences among regions in health risk predictive modelling tools and health indicators, and identified key factors constraining their comparability. The research proposes means to overcome current limitations and the use of population-based health risk prediction for enhanced clinical risk assessment. CONCLUSIONS: The results indicate the need for further efforts to improve both comparability and flexibility of current population-based health risk predictive modelling approaches. Applicability and impact of the proposals for enhanced clinical risk assessment require prospective evaluation.

Predictive model for emergency hospital admission and 6-month readmission.

OBJECTIVES: To study risk factors for and likelihood of unplanned hospital admission and readmission in persons aged >65 years in Catalonia, Spain. STUDY DESIGN: Retrospective cohort study. METHODS: We used data from clinical records of the primary care centers, pharmacy database, and hospital discharge records for persons aged >65 years registered in primary care centers of referral hospitals in the Baix Llobregat healthcare area. Unplanned hospital admission was defined as any unscheduled hospitalization in 2008; unplanned readmission was defined as any unscheduled admission occurring within 6 months after discharge date of index admission. Logistic regression analysis was used to identify predictors of unplanned hospital admission and readmission. RESULTS: The population included 28,430 individuals. Among them, 2103 (7%) experienced an unplanned admission and 365 (1.3%) an unplanned readmission. The readmission rate for the admitted population was 18.7%. The strongest predictive factor of unplanned admission was >2 admissions in the previous 2 years (odds ratio [OR] 24.9, 95% confidence interval [CI] 16.0-38.7 for 2007; OR 15.6, 95% CI 8.6-28.0 for 2006). Factors associated with unplanned readmission were aged >80 years (OR 4.6, 95% CI 3.1-7.1) and >2 admissions during the previous year (OR 20.4, 95% CI 14.1-29.5). The area under the receiver operating characteristics curve was 0.78 for unplanned admission and 0.85 for unplanned readmission in the development sample and 0.76 and 0.81, respectively, in the validation sample. CONCLUSIONS: Aged persons and those who used more hospital services in previous years had a higher probability of hospital admission and readmission.