The impact of the introduction of hospital medical day care programs on inpatient use was studied, to see if there was a reduction in average lengths of stay, cases or patient days, for those diagnostic categories in the programs. The provincial government funded these programs to create an alternative to hospitalization. Studies on the issue of whether or not day care is an alternative or substitutes for inpatient use were examined. Interest in ambulatory care is growing because of the increasing age of the population, increasing duration of chronic illness and increasing costs of hospital services. Three programs at Lions Gate Hospital in North Vancouver, B.C. were chosen: Chronic Obstructive Lung Disease (CO.L.D.) program, Diabetic Day Care,and the Neuro (Neurology) program. The population for study were divided into four groups: those from North and West Vancouver who used Lions Gate Hospital, patients from the rest of the Greater Vancouver Regional District (G.V.R.D.) who used other G.V.R.D. hospitals, arid to allow for 'spill-out' cases, those from North and West Vancouver who used other hospitals in the province and those from the rest of the G.V.R.D. who used Lions Gate Hospital. The methodology involved the use of a multiple time series design which would allow some comparison before and after the introduction of the CO.L.D. program, as well as comparison between the North Shore and the rest of the G.V.R.D. A regression analysis, using a dummy variable for the CO.L.D. program, on average length, of stay, cases and patient days showed no statistically significant results. The data collection period, 1970 to 1979/80, does not provide conclusive answers for Diabetic Day Care, introduced at Lions Gate Hospital in 1966 and in some of the hospitals of the rest of the G.V.R.D. in 1972, or for the Neuro program, introduced at Lions Gate Hospital in 1979. However, population and age adjusted cases and patient days for all three programs are consistently higher in the rest of the G.V.R.D. when compared with North and West Vancouver and deserve further investigation. The implications from this study, that there is no impact from medical day care, programs on rates of inpatient use, is consistent with similar studies on Diabetic Day Care and Day Care Surgery. The health care system does not seem to be able to respond to innovations of this type and they are additions to existing services. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

INTRODUCTION: Unplanned hospital visits have emerged as a quality metric encompassing many aspects of postoperative morbidity and deficiencies in the transition from inpatient to outpatient care. This study aims to identify patient, encounter, and organizational factors that may influence Emergency Department (ED) visits and readmissions following bariatric surgery. METHODS: A modified version of a framework initially proposed by Vest et al. in their systematic review of the determinants of preventable readmissions was used as a conceptual framework for this study. The Michigan Bariatric Surgery Collaborative (MBSC) database was used to identify patients undergoing all primary bariatric procedures at 40 centers with >100 patients in the database from 2006–2015. Multivariate logistic regression modeling was used to identify factors associated with unplanned hospital visits. Using an indirect standardization process, each sites’ observed to expected ratio for 30-day readmission was calculated. The association between each site’s adjusted readmission rate with their rate of ED visits, Emergency Department-Sourced readmissions (EDSR), major complications, and compliance with best practices were calculated with Pearson’s correlation coefficients. RESULTS: Younger age, greater comorbidities, increased length of stay, procedure type, and Medicaid/Medicare insurance were significantly associated with readmissions in a multivariate logistic regression model. There was significant variation among sites’ adjusted rates of readmission, EDSR, best practice compliance, and major complications. There was a moderately strong association between each sites’ adjusted readmission rate with their rate of EDSR (r=0.53), major complications (r=0.53), and ED visits (r=0.55). However, the association between bariatric centers’ compliance with best practices to reduce unplanned hospital visits and their readmission rates was fairly weak (r= -0.14). CONCLUSION: Several individual, encounter, and organization-level characteristics are associated with an increased risk of unplanned visits after bariatric surgery. Bariatric centers are more likely to have higher readmission rates if their site has higher rates of major complications and if their ED is less likely to treat and then discharge bariatric patients. Further examination of organizational characteristics of bariatric programs that affect postoperative readmissions, including ED practices, is needed to better guide future initiatives aimed at improving this quality metric.

No description available.

In recent years, concern about the rising costs of health care has prompted the development of programs aimed at reducing utilization of hospital services and facilities while maintaining an acceptable standard of care. One of the major strategies that has emerged in the effort to accomplish these dual objectives, is utilization management. Although there are a number of different approaches, the primary aim of all utilization management programs is to identify and eliminate unnecessary and inappropriate hospital use. To date, most of the utilization research and program development has taken place in the United States. To a great extent, this effort has focussed on the development and use of norms for utilization based on a breakdown of length of stay data by diagnostic-related groups (DRG's). Canadian interest in this type of approach is reflected in the recent development of data bases defined by case-mix groups (CMG's). However, while continued efforts are being made to refine these schemes, they have been vulnerable to the criticism that they do not provide adequately objective criteria for establishing what constitutes appropriate patterns of hospital use. In addition, because they are based on statistically derived norms, they have been criticized as lacking sufficient clinical relevance to encourage physician support. Since hospital utilization is largely determined by the medical staff, utilization management programs that fail to obtain physician support are unlikely to succeed. An alternative approach, which appears to be gaining in popularity, involves the formulation of criteria which can be used to determine what constitutes appropriate and necessary hospital use. Essentially, it is argued that by directly identifying the source and nature of misutilization, it should be possible to develop more effective strategies for the resolution of identified problems. The American Appropriateness Evaluation Protocol designed by Gertman & Restuccia (1981) is one of the earliest and most highly tested examples of a criterion-based system. In Canada, interest in this type of approach is more recent and, consequently, little attention has as yet been focussed on the development and use of clinical criteria in utilization review and management. One exception, however, is the SWITCH Index System. This system, which was developed and implemented in 1984 by the Peace Arch District Hospital (White Rock, B.C.), makes a direct attempt to identify and eliminate days of hospital stay during which no appropriate acute care services are being provided. The criteria used in this system are classified under the headings Signs, Wind, Intramuscular Therapy, Tubes, Consultant, and Hospice. Patients are considered to be appropriately placed in the hospital if, on any given day, at least one of the specified criteria are met. Otherwise they are classified as Off-Index and action is taken to identify the source of the problem and to initiate corrective action. Since a major objective of the SWITCH system is to identify and eliminate inappropriate use, an observable outcome, if the program is successful, should be a reduction in length of stay. The present study investigated this hypothesis by comparing pre- and post- intervention length of stay trends at the Peace Arch District Hospital. In addition, to take into account any general secular trends in length of stay over time, the Peace Arch length of stay was compared to the length of stay observed for a control group of three peer-group member hospitals. Although data covering the four year period 1982 to 1985, indicated that the length of stay at the Peace Arch District Hospital had been decreasing over time, no component of this general decline could be attributed to the SWITCH Index System. Time series regression analyses failed to detect changes in either the slope or the height of the estimated response curve. However, limitations in the study design do not permit any conclusions regarding the potential effectiveness of this system. Characteristics specific to the Peace Arch District Hospital may have prevented the detection of an effect. In addition, because it is likely that there would be a lag between when the program was implemented and when it might be expected to effect a reduction in length of stay, the follow-up period of eleven months may have been too short for the determination of the program's effectiveness. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Community Medicine / Doctoral / Doctor of Philosophy

In the United States, home health care (HHC) is the most frequently used form of post-acute care services. Majority of the HHC patients are elderly and have known activities of daily living (ADL) dependencies. The role of HHC as a post-acute care provider has been emphasized under the Affordable Care Act (ACA) as it is expected that HHC services will help patients stay in the community and reduce acute care hospitalization. Urinary tract infection (UTI) -related hospitalization is an adverse patient outcome that affects elderly patients in the HHC setting. Studies examining the ADLs of HHC patients are limited. Although dependence in ADLs is a known risk factor for hospitalization, no study has assessed the relationship between ADL dependency and UTI-related hospitalization among HHC patients. This dissertation describes the ADLs of elderly patients receiving HHC services, and examines risk of UTI-related hospitalization among this population, specifically the potential risk of ADL dependency. In Chapter One, the problems of UTI-related hospitalization and ADL dependency are introduced and their significance is described. In Chapter Two, an integrative review of the literature describing methods of assessing ADLs in skilled nursing facilities (SNF) and HHC are described. In Chapter Three, a cross-sectional study elucidating the risk factors for severe ADL dependency and predictors of ADL improvement among HHC patients is reported. In Chapter Four, the risk factors for UTI-related hospitalization among HHC patients is reported. In Chapter Five, findings of the three studies are summarized and conclusions are provided including strengths, limitations, and implications for practice and policy. Andersen’s Behavioral Model was the theoretical framework used for this study. The Andersen model posits that health care utilization is a function of patients predisposing (e.g. age, gender, race/ethnicity), enabling (e.g. living alone, insurance status, living condition, primary care giver) and need factors (e.g. ADL dependency level, comorbidity, impaired decision making). This model fits this dissertation because evidence shows that health care utilization (UTI-related hospitalizations) depends on predisposing, enabling and need factors. This was a retrospective cohort research design study based on secondary analysis of the Outcome and Assessment Information Set (OASIS) data set of 154,801 beneficiaries who received home health care services in 2013. Descriptive statistics, bivariate analysis, and multivariable logistic regression analyses were conducted to examine the effect of each individual variable on the outcomes of interest (severe ADL dependency, ADL improvement and UTI-related hospitalizations). The study population was elderly (mean age 77 years), mostly female (65%) and white (79.8%). Key findings indicated that, (a) over 60% of patients had severe ADL dependency, and impaired decision making is a strong predictor of severe ADL dependency, (b) Overall, patients experienced ADL improvement from admission to discharge. However, blacks experienced significantly less ADL improvement compared to Whites. Longer HHC length of stay was also associated with ADL improvement, and (c) For the UTI-related hospitalization outcome model, multivariable analysis showed that Medicaid insurance, severe ADL dependency and impaired decision making was associated with increased risk for UTI-related hospitalization

Hospitalizations are a major driver of Medicare spending and adverse outcomes for the 5.3 million elderly Americans with dementia. This is a growing problem given aging and longevity trends. Within the home health care setting, about 3.5 million mostly frail elderly Medicare beneficiaries receive care and 27% are hospitalized annually. Estimates of dementia prevalence range from 31 to 60%, yet little is known about the hospitalization of home health care patients with dementia. This study addresses knowledge gaps on the prevalence, characteristics, hospitalization rate and risk factors of these patients, and explores whether hospitalization risk factors are moderated by dementia. A systematic literature review on hospitalization risk factors in the home health care setting was completed and the findings informed the selection of variables and hypotheses for this study. This was a retrospective cohort study and the sample was patients admitted to one large non-profit home health care agency during 2014 (n=57,888). Data were from the Outcome and Assessment Information Set and other home health agency data captured at the start of care. The conceptual framework guiding the analysis was Andersen’s Behavioral Model of Health Services Use. Because more than half of those who would meet clinical criteria for dementia are undiagnosed, the operational definition of dementia for this study was a diagnosis of dementia or Alzheimer’s disease, or an indication of cognitive impairment in the start of care assessment. Multivariable logistic regression was used to identify characteristics of dementia patients and hospitalization risk factors, and to explore dementia as a moderator of hospitalization risk factors. Prevalence of dementia among the study sample was 41.6%. Consistent with prior studies on the general dementia population, older age, Black and Hispanic race/ethnicity, Medicaid eligibility, fall risk, congregate living, more comorbidities, behavioral symptoms, depression, assistance with activities of daily living, and communication disabilities were associated with dementia. However, contrary to prior studies, serious health status, higher need for assistance with activities of daily living, and higher use of health services were negatively associated with dementia. The hospitalization rate for patients with dementia (12.9%) was significantly higher than the rate for patients without dementia (10.7%). Hospitalization risk factors of dementia patients that were consistent with prior studies among home health patients included male gender, Black race, Medicaid eligibility, number of comorbidities, higher need for assistance with activities of daily living, cardiovascular conditions, dyspnea, cancer, diabetes, renal disease, skin ulcers and higher health services use. The moderator analysis found that dementia attenuated the effect of some hospitalization risk factors and had no effect on others. This study was a first step toward better understanding the characteristics and hospitalization risk factors of home health care patients with dementia. Findings from this research can inform practice, policy and future research on home health care patients with dementia.

The aim of the research was to analyse the organisational dynamics surrounding a health care reform implementation process associated with the introduction of coordinated care, which is an Australian Government initiative to introduce structural changes to the funding and delivery of health-care in response to rising health care costs. A longitudinal case study of an implementation team was studied. This included the perceptions and experiences of individuals and institutions within hospitals, the general practice community and Divisions of General Practice. Furthermore, the case study explored organisational structures, decision-making processes and management systems of the Project and included an examination of the difficulties and conflicts that ensued. The broader context of health care reform was also considered. The study found that an effective change management strategy requires clarity around the definition of primary task in health care delivery, particularly when the task is complex and the environment uncertain. This requires a management and support structure able to accommodate the tensions that exists between providing care and managing cost, in a changing and complex system. The case study indicated that where tensions were not managed the functions of providing care and managing costs became disconnected, undermining the integrity of the task and impacting on the effective facilitation of the change process and hence, the capacity of stakeholders to embrace the model of co-ordinated care. Moreover, the micro dynamics of the project team seemed to parallel the macro dynamics of the broader system where economic and health care provision imperatives clash. Through its close analysis of change dynamics, the study provides suggestions for the improved engagement of stakeholders in health care change.

Thesis (Ph.D.)--McMaster University, 2006. / Supervisor: Susan J. Elliott. Includes bibliographical references (leaves 166-171).