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Background: Some patients admitted to acute care hospital require supportive services after discharge. The objective of our review was to identify models and variables that predict the need for supportive services after discharge from acute care hospital.Methods: We performed a systematic review searching the MEDLINE, CINAHL, EMBASE, and COCHRANE databases from inception to May 1st 2017. We selected studies that derived and validated a prediction model for the need for supportive services after hospital discharge for patients admitted non-electively to a medical ward. We extracted cohort characteristics, model characteristics and variables screened and included in final predictive models. Risk of bias was assessed using the Quality in Prognostic Studies tool.Results: Our search identified 3362 unique references. Full text review identified 6 models. Models had good discrimination in derivation (c-statistics > 0.75) and validation (c-statistics > 0.70) cohorts. There was high quality evidence that age, impaired physical function, disabilities in performing activities of daily living, absence of an informal care giver and frailty predict the need for supportive services after discharge. Stroke was the only unique diagnosis with at least moderate evidence of an independent effect on the outcome. No models were externally validated, and all were at moderate or higher risk of bias.Conclusions: Deficits in physical function and activities of daily living, age, absence of an informal care giver and frailty have the strongest evidence as determinants of the need for support services after hospital discharge.Trial Registration: This review was registered with PROSPERO #CRD42016037144. [ABSTRACT FROM AUTHOR]

Background: Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions.Methods: Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred.Results: We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was "complex medical" (49%) and the overall median (IQR) length of stay was 27 (18-48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU).Conclusions: While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population. [ABSTRACT FROM AUTHOR]

Background: Patients who are discharged from hospital after an acute medical illness often have impaired function that prevents them from returning to their previous place of residence. Assessing each patient's post-discharge needs takes time and resources but is important in order to reduce unplanned readmissions and adverse events post-discharge. Methods/design: We will conduct a systematic review to synthesize the evidence on prognostic models and their reported accuracy in predicting the location of discharge after a medical admission to an acute care hospital. We will perform searches in MEDLINE, EMBASE, CINAHL, and COCHRANE databases. Pre-defined study, population, and model characteristics will be reported. We will write a narrative summary of included studies. Methodological quality of the studies will be assessed using the QUIPS tool, and the quality of evidence will be evaluated using the GRADE tool. Discussion: Early and accurate assessment of patient needs for supportive services after discharge has the potential to improve patient outcomes and health system efficiency. This systematic review will identify factors that can accurately predict location of discharge using existing tools and identify priority knowledge gaps to inform future research. [ABSTRACT FROM AUTHOR]

To investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations. Retrospective cohort study. 161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes. We administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death. We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access. Fifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED. The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P =.02) and 14% lower (rate ratio = 0.86, P =.07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access. Residents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates. [ABSTRACT FROM AUTHOR]

Background: Patients who engage in Advance Care Planning (ACP) are more likely to get care consistent with their values. We sought to determine the barriers and facilitators to ACP engagement after discharge from hospital. Methods: Prior to discharge from hospital eligible patients received a standardized conversation about prognosis and ACP. Each patient was given an ACP workbook and asked to complete it over the following four weeks. We included frail elderly patients with a high risk of death admitted to general internal medicine wards at a tertiary care academic teaching hospital. Four weeks after discharge we conducted semi-structured interviews with patients. Interviews were transcribed, coded and analysed with thematic analysis. Themes were categorized according to the theoretical domains framework. Results: We performed 17 interviews. All Theoretical Domain Framework components except for Social/Professional Identity and Behavioral Regulation were identified in our data. Poor knowledge about ACP and physician communication skills were barriers partially addressed by our intervention. Some patients found it difficult to discuss ACP during an acute illness. For others acute illness made ACP discussions more relevant. Uncertainty about future health motivated some participants to engage in ACP while others found that ACP discussions prevented them from living in the moment and stripped them of hope that better days were ahead. Conclusions: For some patients acute illness resulting in admission to hospital can be an opportunity to engage in ACP conversations but for others ACP discussions are antithetical to the goals of hospital care. [ABSTRACT FROM AUTHOR]

Our primary objective was to determine if more comprehensive advance care planning (ACP) documentation was associated with fewer transfers to hospital in the last year of life. Our secondary objective was to determine the impact of ACP processes and practices on hospital transfers in the last year of life. Retrospective cohort study. Long-term care (LTC) residents in Ontario, Canada, 65 years and older who died between January 1, 2017, and May 30, 2018, and resided in a participating LTC home. We administered a survey to directors of care at LTC homes inquiring about ACP practices. Our exposure of interest was living in a home with comprehensive ACP documentation that includes information beyond preferences for cardiopulmonary resuscitation and hospital transfer. Our primary outcome was the number of transfers to hospital in the last year of life. We fit negative binomial regression models to determine the independent effect of comprehensive ACP and other indicators of ACP quality. A total of 157 LTC homes with 6637 decedent residents were included in our study; 2942 lived in homes with comprehensive ACP documentation and 3695 had non-comprehensive ACP documents. Comprehensive documentation was not associated with fewer hospital transfers in the final year of life [incidence rat ratio (IRR), 1.00; 95% CI, 0.91–1.09]. ACP documentation update frequency, availability of ACP documents in the electronic medical record, referring to ACP documents during a health crisis, inclusion of resident values in ACP documents, and involvement of a multidisciplinary team were all associated with fewer transfers to hospital during follow-up in the last year of life. ACP documents that contain information beyond preferences for cardiopulmonary resuscitation and hospital transfer had no association with transfers to hospital, but high-quality ACP practices and processes were associated with fewer transfers. [ABSTRACT FROM AUTHOR]

To describe the rate of do-not-resuscitate (DNR) and do-not-hospitalize (DNH) orders among residents newly admitted into long-term care homes. We also assessed the association between DNR and DNH orders with hospital admissions, deaths in hospital, and survival. A retrospective cohort study. Admissions in all 640 publicly funded long-term care homes in Ontario, Canada, between January 1, 2010 and March 1, 2012 (n = 49,390). We examined if a DNR and/or DNH was recorded on resident's admission assessment. All residents were followed until death, discharge, or end of study to ascertain rates of several outcomes, including death and hospitalization, controlling for resident characteristics. Upon admission, 60.7% of residents were recorded to have a DNR and 14.8% a DNH order. Those who were older, female, widowed, lived in rural facilities, lived in higher income neighborhoods prior to entry, had higher health instability or cognitive impairment, and spoke English or French were more likely to receive a DNR or DNH. Survival time was only slightly shorter for those with a DNR and DNH with a mean of 145 and 133 days, respectively, vs 160 and 153 days for those without a DNR and DNH. After controlling for age, sex, rurality, neighborhood income, marital status, health instability, cognitive performance score, and multimorbidity, DNR and DNH were associated with an odds ratio of 0.57 [95% confidence interval (CI) 0.53-0.62] and 0.41 (95% CI 0.37-0.46) for dying in hospital, respectively. Those with a DNR and DNH, after adjustment, had an incidence rate ratio of 0.87 (95% CI 0.83-0.90) and 0.70 (95% CI 0.67-0.73), respectively, days spent in hospital. This study outlines identifiable factors influencing whether residents have a DNR and/or DNH order upon admission. Both orders led to lower rates, but not absolute avoidance, of hospitalizations near and at death. [ABSTRACT FROM AUTHOR]