Health care professionals in several countries are searching for alternatives to acute hospitalization. In Hallingdal, Norway, selected acute patients are admitted to a community hospital. The aim of this study was to analyse whether acute admission to a community hospital as an alternative to a general hospital had any positive or negative health consequences for the patients.
Patients intended for acute admission to the local community hospital were asked to join a randomized controlled trial. One group of the enrolled patients was admitted as planned (group 1, n = 33), while another group was admitted to the general hospital (group 2, n = 27). Health outcomes were measured by the Nottingham Extended Activity of Daily Living Questionnaire and by collection of data concerning specialist and community health care services in a follow-up year.
After one year, no statistical significant differences in the level of daily function was found between group 1 (admissions to the community hospital) and group 2 (admissions to the general hospital). Group 1 had recorded fewer in-patient days at hospitals and nursing homes, as well as lower use of home nursing, than group 2. For outpatient referrals, the trend was the opposite. However, the differences between the two groups were not at a 5% level of statistical significance.
No statistical significant differences at a 5% level were found related to health consequences between the two randomized groups. The study however, indicates a consistent trend of health benefits rather than risk from acute admissions to a community hospital, as compared to the general hospital. Emergency admission and treatment at a lower-level facility than the hospital thus appears to be a feasible solution for a selected group of patients.
ClinicalTrials.gov NCT01069107 . Registered 2 April 2010.
To evaluate the effect of medical Primary Integrated Interdisciplinary Elder Care at Home (PIECH) on acute hospital use and mortality in a frail elderly population.
Comparison of acute hospital care use for the year before entering the practice (pre-entry) with the most-recent 12-month period (May 1, 2010-April 30, 2011, postentry) for active and discharged patients.
All 248 frail elderly adults enrolled in the practice for at least 12 months who were living in the community and not in nursing homes in Victoria, British Columbia.
Primary geriatric care provided by a physician, nurse, and physiotherapist in participants' homes.
Acute hospital admissions, emergency department (ED) contacts that did not lead to admission, reason for leaving practice, and site of death.
There was a 39.7% (116 vs 70; P = .004) reduction in hospital admissions, 37.6% (1,700 vs 1,061; P = .04) reduction in hospital days, and 20% (120 vs 95; P = .20) reduction in ED contacts after entering the practice. Fifty participants were discharged from the practice, 64% (n = 32) of whom died, 20% (n = 10) moved, and 16% (n = 8) were admitted to nursing homes. Fifteen (46.9%) deaths occurred at home.
Primary Integrated Interdisciplinary Elder Care at Home may reduce acute hospital admissions and facilitate home deaths.
Treatment of stroke patients on specialised stroke units has become more frequent, yet the effect of this treatment has not been determined. In this prospective, community-based study of 1241 unselected acute stroke patients we compared outcome between patients geographically randomised to treatment on a stroke unit or a general neurological/medical ward, from the time of acute admission to the end of rehabilitation. Baseline characteristics were comparable between the two treatment groups regarding age, sex, marital status, prestroke residence, and stroke severity. The patients treated on the stroke unit had higher comorbidity with regard to hypertension and diabetes. Multivariate linear and logistic regression analyses were applied to estimate the independent influence of stroke unit treatment on outcome. Stroke unit treatment significantly reduced in-hospital mortality (OR 0.50), case-fatality rate (OR 0.45), 6-month mortality (OR 0.57), 1-year mortality (0.59, and discharge rate to a nursing home (OR 0.61). The relative chance of being discharged to own home was almost doubled (OR 1.9), and the length of hospital stay reduced by 30% in patients treated on the stroke unit, P
PURPOSE: To study gender differences in functional outcome unexpectedly observed in a follow-up study of stroke patients. DESIGN: Prospective study of hospitalized stroke patients, with evaluations in the subacute phase and after one year. SETTING: Geriatric and general medical wards, and geriatric outpatient clinic of a university hospital serving as general hospital for a defined population. SUBJECTS: All stroke patients admitted during a six-month period (n = 165) were considered for inclusion, of whom 87 could be assessed in the subacute phase and 65 after one year. MAIN OUTCOME MEASURES: Motor function assessed by the Sødring Motor Evaluation of Stroke Patients; cognitive function by the Assessment of Stroke and other Brain Damage; and activities of daily living (ADL) function by the Barthel Index. Nursing-home residency registered after one year. RESULTS: Men achieved a significantly better score than women on most of the scales used. The age-adjusted odds for a man to have a higher Barthel score than a woman was 3.1 (95% confidence interval (CI) 1.3-7.0) in the subacute phase and 3.3 (95% CI 1.2-9.0) after one year. Differences of the same magnitude were seen on the subscales of the motor and cognitive tests. The same trend was observed on all items of the Barthel Index. The males had a lower likelihood to be permanent nursing-home residents after one year, the age-adjusted odds ratio for nursing-home residency for females versus males being 6.3 (95% CI 1.2-65.3). CONCLUSION: Women seem to be functionally more impaired by stroke than men.
Studies have shown that moderate alcohol use confers protection against some of the dominant predictors of long-term care placement, including diminished cognitive functioning, physical disability, and injury. But little is known about the association between alcohol use and the likelihood of placement in long-term care facilities. A nationally representative sample of 5404 community-dwelling Canadians ages 50 years and older at baseline (1994/95) was obtained from the longitudinal National Population Health Survey. Alcohol use categories were developed based on the quantity and frequency of use in the 12 months before the interview. Cox proportional hazards models were used to estimate the association between alcohol use at baseline and subsequent placement in long-term care facilities after adjusting for covariates measured at baseline. During the 14-year follow-up period, 14% of lifetime abstainers, 10% of former drinkers, 7% of infrequent drinkers, 4% of moderate drinkers, and 3% of heavy drinkers were placed in long-term care facilities. Furthermore, the multivariate analysis revealed that abstainers, former drinkers, and infrequent drinkers were more than twice as likely to be placed in long-term care as moderate drinkers. Moderate drinking was protective against placement in long-term care facilities even after adjusting for an array of well-known confounders. The strong protective effect of moderate alcohol use on long-term care entry is likely due to a complex mix of physical, cognitive and psychosocial health factors.
With standard community resources, managing some patients with long-term mental illness can prove difficult, given the high level of care required. How many beds do such patients require? The study examined the prevalence, diagnostic and behavioral characteristics, and residential arrangements of a cohort of these patients in a semirural area of Canada (population of 291,500). The area has always functioned without a psychiatric hospital.
A cross-sectional inquiry was made of all relevant institutions and residential facilities (including the local jail and shelters). Key stakeholders were interviewed and provincial databases were accessed in an effort to identify all adults aged 18 to 65 originating from the catchment area who displayed both a psychotic illness and severe behavioral disturbance necessitating ongoing close supervision. The Riverview Psychiatric Inventory was used to describe and quantify behavioral problems.
Thirty-six patients met the study criteria, for a prevalence of 12.4 per 100,000 in the general population. Most resided in a publicly funded nursing home or a well-staffed rural group home. Four (prevalence of 1.4 per 100,000) had a forensic profile, needed secure settings, and were long-term residents on acute care wards. Only one patient had transferred to a psychiatric hospital outside the catchment area.
Care for this population can be provided outside conventional psychiatric institutions but requires highly supervised long-term residential services in the range of ten to 40 per 100,000 in the population, depending on area characteristics, with urban, socially deprived areas likely having higher needs.
Hallingdal is a rural region in southern Norway. General practitioners (GPs) refer acutely somatically ill patients to any of three levels of care: municipal nursing homes, the regional community hospital or the local general hospital. The objective of this paper is to describe the patterns of referrals to the three different somatic emergency service levels in Hallingdal and to elucidate possible explanations for the differences in referrals.
Quantitative methods were used to analyse local patient statistics and qualitative methods including focus group interviews were used to explore differences in referral rates between GPs. The acute somatic admissions from the six municipalities of Hallingdal were analysed for the two-year period 2010-11 (n?=?1777). A focus group interview was held with the chief municipal medical officers of the six municipalities. The main outcome measure was the numbers of admissions to the three different levels of acute care in 2010-11. Reflections of the focus group members about the differences in admission patterns were also analysed.
Acute admissions at a level lower than the local general hospital ranged from 9% to 29% between the municipalities. Foremost among the local factors affecting the individual doctor's admission practice were the geographical distance to the different places of care and the GP's working experience in the local community.
The experience from Hallingdal demonstrates that GPs use available alternatives to hospitalization but to varying degrees. This can be explained by socio-demographic factors and factors related to the medical reasons for admission. However, there are also important local factors related to the individual GP and the structural preparedness for alternatives in the community.
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The Norwegian Centre for Movement Disorders, Stavanger University Hospital, Stavanger, Norway; Department of Neurology, Stavanger University Hospital, Stavanger, Norway; Institute of Clinical Medicine, University of Bergen, Norway. Electronic address: email@example.com.
Clinical staging of Parkinson's disease (PD) is important for patient management and prognosis. The non-motor and functional features visual hallucinations, recurrent falls, dementia and nursing home placement are currently not included in clinical staging schemes, but have been suggested as clinical milestones with important prognostic implications in advanced PD. In this study, we sought to evaluate the potential of these four milestone events for clinical staging and prognosis during the early years of the disease.
We recruited 185 patients with incident PD and monitored prospectively every six months through seven years for emergence and consequences of four clinical milestones.
One or more milestones were reached in 53.0%. Of the patients who reached the milestones, visual hallucinations appeared after a median of 3.3 (interquartile range 1.3-4.9) years from diagnosis, recurrent falls after 3.8 (2.8-5.2) years, dementia after 4.0 (2.1-4.8) years and nursing home placement after 5.4 (3.9-6.7) years. Presence of any milestone was associated with occurrence of other milestones (relative risks 1.9-6.3; all p = 0.001). Experiencing two or more milestones increased the risk of death during the study (relative risk 2.7, p = 0.03).
In early PD, visual hallucinations, recurrent falls, dementia and nursing home placement appear closely interrelated, possibly reflecting a shared neuropathological disease stage. All events convey important and sinister information on PD status and prognosis and are relatively easily accessible during routine clinical consultations. Therefore, they appear highly useful as clinical PD milestones and could possibly be incorporated into a novel disease rating scale.