Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis

Doheny, Megan; Agerholm, Janne; Orsini, Nicola; Schön, Pär; Burström, Bo

doi:10.1136/bmjopen-2019-036182

Cited by 8 publications

(17 citation statements)

References 28 publications

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“…They often have poorer compliance to medical treatment [37] and might therefore differ in their ability to follow suggested rehabilitation measures. From previous studies, we know that the proportion of people with low socioeconomic position is higher in Norrtälje Municipality than in the rest of Region Stockholm and this might have affected the results [25]. Data on socioeconomic position was not collected in SHAR; however, we were able to compare Norrtälje Municipality with Södertälje Municipality where the socioeconomic composition is more comparable.…”

Section: Discussionmentioning

confidence: 99%

“…The population in Norrtälje differs to some extend from the total population in the rest of Region Stockholm. There is a higher proportion of people with low income, there are a lower proportion of people born outside Sweden, and the proportion of 80+ year olds are slightly lower [25]. The other hospitals are scattered around Region Stockholm and covers all hospitals in Region Stockholm that provides THR.…”

Section: Methodsmentioning

confidence: 99%

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Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

Agerholm

Teni

Sundbye

et al. 2022

BMC Health Serv Res

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Background Coordination, cooperation and efficient use of resources is vital for the health- and social care sector if it is to meet the needs of an aging population. Integrated care is a patient-centred approach to provision of care aiming to improve quality of care and overcome fragmented care through co-productive partnerships and may positively affect quality of care and health outcomes, especially among those in need of highly coordinated care services. Aim To compare patient-reported outcomes (PROs) among patients undergoing total hip replacement (THR) in the integrated care system in Norrtälje Municipality and in the standard care system in other municipalities in Region Stockholm, Sweden. Methods Swedish Hip Arthroplasty Register PRO data during 2008–2015 were compared 1 year after THR among patients (≥50 years) in integrated care (n = 407) and standard care (n = 3501) systems using linear (EQ VAS score), logistic (EQ-5D-3L dimensions) and negative binomial (hip pain VAS score) regressions. Analyses were adjusted for the preoperative factors age, sex, BMI, ASA class and type of incision. Results 1-year postoperatively, patients in the integrated care system did not report their health significantly different from patients receiving standard care. Exceptions: Female patients in integrated care reported less problems with self-care (OR:0.52; 0.29–0.96) and patients above 70 years reported more problems with mobility (OR: 1.37; 1.01–1.87). Conclusion No significant differences were found between the two care systems for postoperative PROs. A longer follow-up time and analyses by socioeconomic groups would be valuable.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

Agerholm

Teni

Sundbye

et al. 2022

BMC Health Serv Res

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“…In Sweden, as in other high-income countries, the fragmentation of health and social care systems has become more visible during the COVID-19 pandemic, and there is a need to establish channels that ensure continuous and rapid coordination of services from different care providers and levels of organisations 32 33. Research has shown that integrated care, that is, co-ordination between different care providers, can reduce ED visits, hospital admissions, and the length of hospital stay 34 35…”

Section: Discussionmentioning

confidence: 99%

Individual and contextual predictors of emergency department visits among community-living older adults: a register-based prospective cohort study

et al. 2022

Self Cite

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ObjectivesTo examine the extent to which contextual factors explain emergency department (ED) visits and ED revisits, additional to that explained by individual factors.DesignA register-based prospective cohort study.SettingSwedish region of Dalarna.ParticipantsParticipants were 16 543 community-living adults aged 80 or older who were residents of the Dalarna region of Sweden, excluding older adults who moved out of Dalarna or into residential care during the study period.Outcome measuresDependent variables were initial ED visit, and at least one ED revisit within 30 days of an initial ED visit.ResultsApproximately 36% of the participants visited the ED during the study period with 18.9% returning to the ED within 30 days. For both initial ED visits and ED revisits, the addition of contextual factors to models containing individual factors significantly improved model fit (p<0.001; p<0.022) and the amount of variance explained in the outcome. In the final models, initial ED visit was significantly associated with older age, number of chronic diseases, receipt of home help, number of primary care visits, proportion of 80+ in the population and shorter distance to the ED; while an ED revisit was significantly associated with greater use of social care, number of hospital admissions and disposition (discharged; admitted to hospital) at initial ED visit.ConclusionContextual factors explain variance in initial ED visit, additional to that explained by individual factors alone, which indicates inequitable access to ED care. These findings suggest considering local variations in contextual factors in order to improve health-related outcomes among older adults.

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“…In spite of these findings, it was reported that IC has not resulted in a sustained reduction in hospital use. Other countries reported similar evidence: in Denmark, the IC initiative observed no effect on the use of ED; in the UK, pilot IC studies showed no difference in use of ED and only some reduced visits to ED in Australia for people over 65 with chronic COPD (Doheny et al , 2019). It is expected that any changes in use of ED and emergency admission, from integrated care services will take five to six years to take effect (Lloyd et al , 2021).…”

Section: Introductionmentioning

confidence: 88%

“…An evaluation study in the UK found that the implementation of integrated care was associated with a decrease in the trend of ED visits only in the post intervention period, compared to the pre-interventions among all those of 65+ years. It is suggested that the rate of ED visits would have increased if integrated care (IC) was not introduced (Doheny et al , 2019). The same study found that there was no infrastructure for information sharing between health and social care practitioners.…”

Section: Introductionmentioning

confidence: 99%

Upstreamist leaders: how risk factors for unscheduled return visits (URV) to the emergency department can inform integrated healthcare

Quintero

Indrasena²,

Fox

et al. 2022

LHS

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Purpose This paper aims to report on research undertaken in an National Health Service (NHS) emergency department in the north of England, UK, to identify which patients, with which clinical conditions are returning to the emergency department with an unscheduled return visit (URV) within seven days. This paper analyses the data in relation to the newly introduced Integrated Care Boards (ICBs). The continued upward increase in demand for emergency care services requires a new type of “upstreamist”, health system leader from the emergency department, who can report on URV data to influence the development of integrated care services to reduce further demand on the emergency department. Design/methodology/approach Patients were identified through the emergency department symphony data base and included patients with at least one return visit to emergency department (ED) within seven days. A sample of 1,000 index visits between 1 January 2019–31 October 2019 was chosen by simple random sampling technique through Excel. Out of 1,000, only 761 entries had complete data in all variables. A statistical analysis was undertaken using Poisson regression using NCSS statistical software. A review of the literature on integrated health care and its relationship with health systems leadership was undertaken to conceptualise a new type of “upstreamist” system leadership to advance the integration of health care. Findings Out of all 83 variables regressed with statistical analysis, only 12 variables were statistically significant on multi-variable regression. The most statistically important factor were patients presenting with gynaecological disorders, whose relative rate ratio (RR) for early-URV was 43% holding the other variables constant. Eye problems were also statistically highly significant (RR = 41%) however, clinically both accounted for just 1% and 2% of the URV, respectively. The URV data combined with “upstreamist” system leadership from the ED is required as a critical mechanism to identify gaps and inform a rationale for integrated care models to lessen further demand on emergency services in the ED. Research limitations/implications At a time of significant pressure for emergency departments, there needs to be a move towards more collaborative health system leadership with support from statistical analyses of the URV rate, which will continue to provide critical information to influence the development of integrated health and care services. This study identifies areas for further research, particularly for mixed methods studies to ascertain why patients with specific complaints return to the emergency department and if alternative pathways could be developed. The success of the Esther model in Sweden gives hope that patient-centred service development could create meaningful integrated health and care services. Practical implications This research was a large-scale quantitative study drawing upon data from one hospital in the UK to identify risk factors for URV. This quality metric can generate important data to inform the development of integrated health and care services. Further research is required to review URV data for the whole of the NHS and with the new Integrated Health and Care Boards, there is a new impetus to push for this metric to provide robust data to prioritise the need to develop integrated services where there are gaps. Originality/value To the best of the authors’ knowledge, this is the first large-scale study of its kind to generate whole hospital data on risk factors for URVs to the emergency department. The URV is an important global quality metric and will continue to generate important data on those patients with specific complaints who return back to the emergency department. This is a critical time for the NHS and at the same time an important opportunity to develop “Esther” patient-centred approaches in the design of integrated health and care services.

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Impact of integrated care on trends in the rate of emergency department visits among older persons in Stockholm County: an interrupted time series analysis

Cited by 8 publications

References 28 publications

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

Patient-reported outcomes among patients undergoing total hip replacement in an integrated care system and in a standard care system in Region Stockholm, Sweden

Individual and contextual predictors of emergency department visits among community-living older adults: a register-based prospective cohort study

Upstreamist leaders: how risk factors for unscheduled return visits (URV) to the emergency department can inform integrated healthcare

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