The Association between Home Healthcare and Burdensome Transitions at the End-of-Life in People with Dementia: A 12-Year Nationwide Population-Based Cohort Study

Abstract

Background: For people with dementia, burdensome transitions may indicate poorer-quality end-of-life care. Little is known regarding the association between home healthcare (HHC) and these burdensome transitions. We aimed to investigate the impact of HHC on transitions and hospital/intensive care unit (ICU) utilisation nearing the end-of-life for people with dementia at a national level. Methods: A nested case-control analysis was applied in a retrospective cohort study using a nationwide electronic records database. We included people with new dementia diagnoses who died during 2002–2013 in whole population data from the universal healthcare system in Taiwan. Burdensome transitions were defined as multiple hospitalisations in the last 90 days (early transitions, ET) or any hospitalisation or emergency room visit in the last three days of life (late transitions, LT). People with (cases) and without (controls) burdensome transitions were matched on a ratio of 1:2. We performed conditional logistic regression with stratified analyses to estimate the adjusted odds ratio (OR) and 95% confidence interval (CI) of the risks of transitions. Results: Among 150,125 people with new dementia diagnoses, 61,399 died during follow-up, and 31.1% had burdensome transitions (50% were early and 50% late). People with ET had the highest frequency of admissions and longer stays in hospital/ICU during their last year of life, while people with LT had fewer hospital/ICU utilisation than people without end-of-life transitions. Receiving HHC was associated with an increased risk of ET (OR = 1.14, 95 % CI: 1.08–1.21) but a decreased risk of LT (OR = 0.89, 95 % CI 0.83–0.94). In the people receiving HHC, however, those who received longer duration (e.g., OR = 0.50, 95 % CI: 0.42–0.60, >365 versus ≤30 days) or more frequent HHC or HHC delivered closer to the time of death were associated with a remarkably lower risk of ET. Conclusions: HHC has differential effects on early and late transitions. Characteristics of HHC such as better continuity or interdisciplinary coordination may reduce the risk of transitions at the end-of-life. We need further studies to understand the longitudinal effects of HHC and its synergy with palliative care, as well as the key components of HHC that achieve better end-of-life outcomes.

Healthcare Utilization in Different Stages among Patients with Dementia: A Nationwide Population-Based Study

“…Patients were selected using the following criteria: (i) at least 3 outpatient service claims with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for dementia (290.1x-290.4x, 291.2, 292.82, 294.1x, 294.8, 331.0, 331.1x, 331.2, 331.82) within 1 year after the first dementia diagnosis code; and (ii) any single hospitalization for dementia related to the principal diagnosis codes. The criteria were also applied in our previous studies [13,14]. To ensure that the study included only patients with their first diagnosis of dementia, we excluded patients who had a history of dementia before 2002.…”

Admiral Nurse Case Management within Enhanced Health in Care Homes

“…Similarly, they can offer support and guidance on prognosis and the trajectory of dementia which may reduce inappropriate and burdensome transitions to hospital which often result in poorer quality end-of-life care [59]. There is evidence to suggest that people in the advanced "terminal" stages of dementia are often exposed to overly aggressive, burdensome or futile treatments and consequently there is a need for expertise in dementia care at end-of-life [60].…”

Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia

“…16 Community-based palliative care services have been associated with fewer hospital admissions in people with dementia in Australia 17 and the USA 18 However, people with dementia experience several barriers to access palliative care services. 19 Being the first point of contact, GPs play an important role providing end-of-life care, and contacts with GPs 20 and home health care 21 have been associated with lower risk of end-of-life admissions to hospital among older adults and people with dementia. It is not known how this relationship is affected by the frequency and length of contacts, 21 the level of continuity of care (CoC) experienced, 22 or whether palliative care needs are being identified by the GP.…”

“…19 Being the first point of contact, GPs play an important role providing end-of-life care, and contacts with GPs 20 and home health care 21 have been associated with lower risk of end-of-life admissions to hospital among older adults and people with dementia. It is not known how this relationship is affected by the frequency and length of contacts, 21 the level of continuity of care (CoC) experienced, 22 or whether palliative care needs are being identified by the GP. 23 The aim of this study was (1) to describe primary care service utilization among individuals with dementia in the last year of life, and (2) explore associations between contacts, continuity of care with GPs, and palliative care needs identification with unplanned hospital admissions among people dying with dementia in the last 90 days of life.…”