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Research

Regional variations of care in home care and long-term care: a retrospective cohort study

Paul C. Hébert, Anne Morinville, Andrew Costa, George Heckman and John Hirdes
May 19, 2019 7 (2) E341-E350; DOI: https://doi.org/10.9778/cmajo.20180086
Paul C. Hébert
Département de médecine (Hébert), Université de Montréal and Centre hospitalier de l’Université de Montréal, Montréal, Que.; Novartis Pharmaceuticals Canada Inc. (Morinville), Dorval, Que.; Centre de recherche du Centre hospitalier de l’Université de Montréal (Hébert) (Morinville, during the conduct of the study), Montréal, Que.; Departments of Medicine, and Health Research Methods, Evidence, and Impact (Costa), McMaster University, Hamilton, Ont.; Research Institute for Aging, School of Public Health and Health Systems (Heckman); School of Public Health and Health Systems (Hirdes), University of Waterloo, Waterloo, Ont.
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Anne Morinville
Département de médecine (Hébert), Université de Montréal and Centre hospitalier de l’Université de Montréal, Montréal, Que.; Novartis Pharmaceuticals Canada Inc. (Morinville), Dorval, Que.; Centre de recherche du Centre hospitalier de l’Université de Montréal (Hébert) (Morinville, during the conduct of the study), Montréal, Que.; Departments of Medicine, and Health Research Methods, Evidence, and Impact (Costa), McMaster University, Hamilton, Ont.; Research Institute for Aging, School of Public Health and Health Systems (Heckman); School of Public Health and Health Systems (Hirdes), University of Waterloo, Waterloo, Ont.
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Andrew Costa
Département de médecine (Hébert), Université de Montréal and Centre hospitalier de l’Université de Montréal, Montréal, Que.; Novartis Pharmaceuticals Canada Inc. (Morinville), Dorval, Que.; Centre de recherche du Centre hospitalier de l’Université de Montréal (Hébert) (Morinville, during the conduct of the study), Montréal, Que.; Departments of Medicine, and Health Research Methods, Evidence, and Impact (Costa), McMaster University, Hamilton, Ont.; Research Institute for Aging, School of Public Health and Health Systems (Heckman); School of Public Health and Health Systems (Hirdes), University of Waterloo, Waterloo, Ont.
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George Heckman
Département de médecine (Hébert), Université de Montréal and Centre hospitalier de l’Université de Montréal, Montréal, Que.; Novartis Pharmaceuticals Canada Inc. (Morinville), Dorval, Que.; Centre de recherche du Centre hospitalier de l’Université de Montréal (Hébert) (Morinville, during the conduct of the study), Montréal, Que.; Departments of Medicine, and Health Research Methods, Evidence, and Impact (Costa), McMaster University, Hamilton, Ont.; Research Institute for Aging, School of Public Health and Health Systems (Heckman); School of Public Health and Health Systems (Hirdes), University of Waterloo, Waterloo, Ont.
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John Hirdes
Département de médecine (Hébert), Université de Montréal and Centre hospitalier de l’Université de Montréal, Montréal, Que.; Novartis Pharmaceuticals Canada Inc. (Morinville), Dorval, Que.; Centre de recherche du Centre hospitalier de l’Université de Montréal (Hébert) (Morinville, during the conduct of the study), Montréal, Que.; Departments of Medicine, and Health Research Methods, Evidence, and Impact (Costa), McMaster University, Hamilton, Ont.; Research Institute for Aging, School of Public Health and Health Systems (Heckman); School of Public Health and Health Systems (Hirdes), University of Waterloo, Waterloo, Ont.
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Figures

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  • Figure 1:
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    Figure 1:

    State-space diagram for possible transitions from home care (A) and long-term (B) care in multistate Markov model. At admission to home care (A) or long-term care (B), clients can be in State 1 (CHESS score = 0), State 2 (CHESS score = 1 or 2) or State 3 (CHESS score ≥ 3), with State 3 representing the greatest health instability and State 1 the least health instability. From this initial state, clients who remain in home care (A) or long-term care (B) can improve (e.g., a transition from State 2 to State 1, or a transition from State 3 to State 1 or 2) or can worsen (e.g., transition from State 1 to State 2 or 3, or transition from State 2 to State 3). A client can also transition out of home care (A) from 1 of the 3 initial admission states (State 1, 2 or 3) to 1 of 4 possible discharge possibilities: discharge to a long-term care facility (State 4), discharge from home care (no longer requiring services, State 5), discharge to hospital (State 6) or death (State 7). A long-term care resident (B) can transition out of long-term care from 1 of the 3 initial admission states (State 1, 2 and 3) to 1 of 4 possible discharge possibilities: discharge home (State 4), discharge to another care setting (State 5), discharge to hospital (State 6) or death (State 7). In Figure 1A the broken lines reflect transitions between health states for those remaining in home care. The solid lines reflect transitions to “absorbing states” outside of the home care. In Figure 1B the broken lines reflect transitions between health states within the long-term care facility. The solid lines reflect transitions to “absorbing states” outside of the long-term care facility.

  • Figure 2:
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    Figure 2:

    Unadjusted rates of transitions from home care by CHESS score and by province. The figure depicts the percentage of home care clients who were admitted to long-term care, who died (at home or in hospital) or who were admitted to hospital but did not die there within 6 months of intake assessment, by CHESS score at intake, in Ontario (ON), Alberta (AB) and British Columbia (BC). Note: CHESS = Changes in Health, End-Stage Disease, Signs, and Symptoms Scale.

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    Figure 3:

    Unadjusted rates of transitions from long-term care by CHESS score and by province. The figure depicts the percentage of residents who died (in a long-term care facility or hospital) or were admitted to hospital but did not die there within 90 days of admission assessment, by CHESS score at admission, in Ontario (ON), Alberta (AB) and British Columbia (BC). Note: CHESS = Changes in Health, End-Stage Disease, Signs, and Symptoms Scale.

Tables

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    Table 1:

    Baseline characteristics of 254 664 patients who received home care services

    Covariate/domainNo. (%) of patients; region
    Ontario
    n = 194 094
    British Columbia
    n = 46 359
    Alberta
    n = 13 983
    Yukon
    n = 228
    Overall
    n = 254 664*
    Age group, yr
     65–7443 941 (23)6592 (14)2838 (20)69 (30)53 440 (21)
     75–8483 866 (43)18 767 (40)5925 (42)107 (47)108 665 (43)
     85–9461 763 (33)19 181 (41)4885 (35)50 (22)85 879 (34)
     ≥ 954524 (2)1819 (4)335 (2)2 (1)6680 (3)
    Sex
     Female115 723 (60)27 749 (60)8331 (60)122 (54)151 925 (60)
    Marital status
     Married†88 506 (46)16 049 (35)NA70 (31)104 625 (43)
    CHESS score
     032 708 (17)10 842 (23)4642 (33)79 (35)48 271 (19)
     160 761 (31)14 031 (30)4186 (30)71 (31)79 049 (31)
     257 666 (30)12 781 (28)3111 (23)44 (19)73 602 (29)
     333 266 (17)6284 (14)1547 (11)24 (11)41 121 (16)
     49030 (5)2165 (5)456 (3)9 (4)11 660 (5)
     5663 (0)256 (1)41 (0)1 (0)961 (0)
    Diagnoses
     Congestive heart failure22 860 (12)6763 (15)2026 (14)18 (8)31 667 (12)
     Chronic obstructive pulmonary disease33 603 (17)8177 (18)2850 (20)53 (23)44 683 (18)
     Pneumonia6566 (3)835 (2)447 (3)6 (3)7854 (3)
     Diabetes51 006 (26)10 172 (22)3408 (24)54 (24)64 640 (25)
     Arthritis89 113 (46)17 804 (38)6617 (47)112 (49)113 646 (45)
     Renal infection13 803 (7)5290 (11)1099 (8)6 (3)20 198 (8)
     Urinary tract infection10 724 (6)2322 (5)903 (6)8 (4)13 957 (5)
     Dementia41 128 (21)17 234 (37)3620 (26)51 (22)62 033 (24)
     Depression22 388 (12)7237 (16)1906 (14)16 (7)31 547 (12)
     Cancer34 531 (18)5593 (12)1971 (14)37 (16)42 132 (17)
    Nurse visits in the last 7 d54 906 (28)5942 (13)4043 (29)46 (20)64 937 (25)
    Cognitive Performance Scale score
     075 913 (39)11 198 (24)6241 (45)98 (43)93 450 (37)
     1 or 298 933 (51)26 766 (58)6390 (46)108 (47)132 197 (52)
     3 or 414 340 (7)6612 (14)1010 (7)21 (9)21 983 (9)
     5 or 64908 (3)1783 (4)342 (2)1 (0)7034 (3)
    Activities of Daily Living Hierarchy Scale score
     0119 003 (61)27 841 (60)10 759 (77)190 (83)157 793 (62)
     1 or 253 350 (27)12 647 (27)2343 (17)28 (12)68 368 (27)
     ≥ 321 741 (11)5871 (13)881 (6)10 (4)28 503 (11)
    Functional improvements in activities of daily living
     Yes61 273 (32)11 045 (24)3869 (28)73 (32)76 260 (30)
    • Note: CHESS = Changes in Health, End-Stage Disease, Signs, and Symptoms Scale; NA = not applicable.

    • ↵* Unless indicated otherwise.

    • ↵† n = 240 680.

    • View popup
    Table 2:

    Baseline characteristics of 162 045 patients living in long-term care facilities

    Covariate/domainNo. (%) of patients; region
    Ontario
    n = 113 552
    British Columbia
    n = 22 732
    Alberta
    n = 25 761
    Overall
    n = 162 045*
    Age group, yr
     65–7412 317 (11)2409 (11)2980 (12)17 706 (11)
     75–8441 164 (36)7783 (34)8874 (34)57 821 (36)
     85–9452 842 (47)10 771 (47)11 844 (46)75 457 (47)
     ≥ 957229 (6.4)1769 (8)2063 (8)11 061 (7)
    Sex
     Female74 023 (65)14 407 (63)15 966 (62)104 396 (64)
    Marital status
     Married†35 651 (31)6666 (29)NA42 317 (31)
    Diagnoses
     Congestive heart failure16 504 (15)3626 (16)4701 (18)24 831 (15)
     Chronic obstructive pulmonary disease18 375 (16)3374 (15)5291 (21)27 040 (17)
     Pneumonia2103 (2)347 (2)566 (2)3016 (2)
     Diabetes29 677 (26)4739 (21)6079 (24)40 495 (25)
     Arthritis46 807 (41)6753 (30)9371 (36)62 931 (39)
     Renal infection11 791 (10)2769 (12)2755 (11)17 315 (11)
     Urinary tract infection9758 (9)1883 (8)3108 (12)14 749 (9)
     Dementia70 244 (62)14 521 (64)15 597 (61)100 362 (62)
     Depression25 913 (23)4308 (19)7223 (28)37 444 (23)
     Cancer12 060 (11)2246 (10)2666 (10)16 972 (11)
    CHESS score
     055 901 (49)13 431 (59)9081 (35)78 413 (48)
     136 206 (32)5882 (26)8034 (31)50 122 (31)
     215 305 (13)2431 (11)5425 (21)23 161 (14)
     34552 (4)735 (3)2257 (9)7544 (5)
     41363 (1)213 (1)877 (3)2453 (2)
     5225 (0)40 (0)87 (0)352 (0)
    Physician examination in last 14 d96 057 (85)11 708 (52)21 038 (82)128 803 (80)
    Cognitive Performance Scale score
     014 444 (13)2134 (9)1930 (7)18 508 (11)
     1 or 241 830 (37)8100 (36)8214 (33)58 144 (36)
     3 or 446 466 (41)9464 (42)11 640 (45)67 570 (42)
     5 or 610 812 (10)3034 (13)3977 (15)17 823 (11)
    Activities of Daily Living Hierarchy Scale score
     05238 (4.6)2298 (10.1)517 (2)8053 (5)
     1 or 229 518 (26)8157 (36)5441 (21)43 116 (27)
     ≥ 378 796 (69)12 277 (54)19 803 (77)110 876 (68)
    Functional improvements in activities of daily living
     Yes27 578 (24)5930 (26)6890 (27)40 398 (25)
    Advanced directive
     Do not hospitalize26 679 (25)4557 (24)4664 (31)35 900 (26)
     Do not resuscitate74 464 (70)13 982 (72)12 360 (83)100 806 (71)
    Facility size, no. of beds
     1–493764 (3)1426 (6)2468 (10)7658 (5)
     50–9927 656 (24)7046 (31)6363 (25)41 065 (25)
     100–14957 147 (50)6559 (29)11 123 (43)74 829 (46)
     ≥ 15024 985 (22)7701 (34)5807 (23)38 493 (24)
    • Note: CHESS = Changes in Health, End-Stage Disease, Signs, and Symptoms Scale; NA = not applicable.

    • ↵* Unless indicated otherwise.

    • ↵† n = 136 284.

    • View popup
    Table 3:

    Effect of province on home care transitions: odds of transition from baseline health instability score in home care to another health instability score (if the patient stayed in home care) or to hospital, death, long-term care or other setting at 6-mo follow-up

    RegionAdjusted odds ratio (95% CI) for transition at 6-mo follow-up (T2)*
    Remained in home care; health instability score†Admitted to hospitalDiedAdmitted to long-term careDischarged to other setting‡
    Low (0)Medium (1, 2)High (≥ 3)
    Alberta (Ref. = Ontario); health instability score at baseline (T1)†
     Low (0)–0.82 (0.75–0.90)NS2.08 (1.92–2.24)1.80 (1.48–2.20)0.26 (0.18–0.36)0.67 (0.62–0.72)
     Medium (1, 2)1.85 (1.71–2.00)–NS2.44 (2.30–2.59)2.11 (1.84–2.42)0.42 (0.35–0.49)1.14 (1.07–1.21)
     High (≥ 3)4.83 (3.82–6.12)1.80 (1.51–2.16)–3.77 (3.24–4.40)2.63 (2.09–3.32)NS2.67 (2.26–3.16)
    British Columbia (Ref. = Ontario); health instability score at baseline (T1)†
     Low (0)–1.44 (1.38–1.51)1.98 (1.80–2.18)1.46 (1.39–1.54)0.46 (0.37–0.56)0.55 (0.48–0.62)0.31 (0.30–0.33)
     Medium (1, 2)1.67 (1.60–1.73)–1.45 (1.39–1.52)1.39 (1.35–1.43)0.54 (0.49–0.60)0.76 (0.72–0.81)0.62 (0.60–0.64)
     High (≥ 3)3.13 (2.81–3.481.39 (1.30–1.48)–1.28 (1.21–1.35)0.39 (0.34–0.45)0.85 (0.78–0.93)1.53 (1.44–1.63)
    • Note: CI = confidence interval, NS = not significant, Ref. = reference category.

    • ↵* Multistate transition models were adjusted for home nursing visits, age, sex, marital status, Activities of Daily Living Hierarchy Scale score, Cognitive Performance Scale score, diagnosis (binary variables for chronic obstructive pulmonary disease, pneumonia, diabetes, arthritis, renal failure, urinary tract infection, Alzheimer’s dementia and related dementias, heart failure, cancer, depression), day of stay and functional improvement potential.

    • ↵† Health instability was measured with the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS); higher scores indicate greater instability.

    • ↵‡ Other settings typically involved discontinuation of home care services (i.e., discharge from the program).

    • View popup
    Table 4:

    Effect of province on long-term care facility transitions (ref = Ontario): odds of transition from baseline health instability score in long-term care to another health instability score (if the patient remained in the same long-term care facility) or to hospital, death, another setting or home at 90-d follow-up

    RegionAdjusted odds ratio (95% CI) for transition at 90-d follow-up (T2)*
    Remained in the same long-term care facility; health instability score†Admitted to hospitalDiedDischarged to other setting‡Discharged home
    Low (0)Medium (1, 2)High (≥ 3)
    Alberta (Ref. = Ontario); health instability score at baseline (T1)†
    Low (0)–1.43 (1.37–1.48)2.02 (1.83–2.23)0.38 (0.35–0.40)1.21 (1.09–1.36)2.31 (1.93–2.77)NS
    Medium (1, 2)0.96 (0.92–0.99)–1.46 (1.38–1.54)0.39 (0.37–0.41)0.93 (0.87–0.98)1.46 (1.24–1.71)NS
    High (≥ 3)0.76 (0.66–0.87)0.77 (0.71–0.85)–0.39 (0.34–0.43)0.52 (0.47–0.58)NSNS
    British Columbia (Ref. = Ontario); health instability score at baseline (T1)†
    Low (0)–0.84 (0.77–0.93)0.84 (0.77–0.93)0.44 (0.42–0.46)1.39 (1.28–1.51)0.74 (0.62–0.90)0.50 (0.42–0.60)
    Medium (1, 2)NS–1.15 (1.08–1.22)0.51 (0.48–0.53)1.35 (1.27–1.43)NS0.55 (0.43–0.70)
    High (≥ 3)0.40 (0.34–0.48)0.55 (0.50–0.61)–0.33 (0.29–0.37)0.58 (0.52–0.65)0.51 (0.31–0.83)0.52 (0.27–0.99)
    • Note: CI = confidence interval, NS = not significant, Ref. = reference category.

    • ↵* Multistate transition models adjusted for physician visits, age, gender, marital status, ADL Hierarchy scale score, Cognitive Performance Scale score, diagnosis (binary variables for Chronic Obstructive Pulmonary Disease, pneumonia, diabetes, arthritis, renal failure, Urinary tract infection, Alzheimer’s Dementia and Related Dementias, heart failure, cancer, depression), facility size, Advanced directives (i.e., do not resuscitate, do not hospitalize), day of stay, functional improvement potential.

    • ↵† Health instability was measured with the Changes in Health, End-Stage Disease, Signs, and Symptoms Scale (CHESS); higher scores indicate greater instability.

    • ↵‡ Other settings for transitions from nursing homes included discharges to other nursing homes, assisted living or retirement homes.

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Regional variations of care in home care and long-term care: a retrospective cohort study
Paul C. Hébert, Anne Morinville, Andrew Costa, George Heckman, John Hirdes
Apr 2019, 7 (2) E341-E350; DOI: 10.9778/cmajo.20180086

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Regional variations of care in home care and long-term care: a retrospective cohort study
Paul C. Hébert, Anne Morinville, Andrew Costa, George Heckman, John Hirdes
Apr 2019, 7 (2) E341-E350; DOI: 10.9778/cmajo.20180086
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