The association between home care visits and same-day emergency department use: a case-crossover study [Research]

BACKGROUND:

The extent to which home care visits contribute to the delay or avoidance of emergency department use is poorly characterized. We examined the association between home care visits and same-day emergency department use among patients receiving publicly funded home care.

METHODS:

We conducted a population-based case–crossover study among patients receiving publicly funded home care in the Hamilton–Niagara–Haldimand–Brant region of Ontario between January and December 2015. Within individuals, all days with emergency department visits after 5 pm were selected as cases and matched with control days from the previous week. The cohort was stratified according to whether patients had ongoing home care needs (“long stay”) or short-term home care needs (“short stay”). We used conditional logistical regression to estimate the association between receiving a home care visit during the day and visiting the emergency department after 5 pm on the same day.

RESULTS:

A total of 4429 long-stay patients contributed 5893 emergency department visits, and 2836 short-stay patients contributed 3476 visits. Receiving a home care nursing visit was associated with an increased likelihood of visiting the emergency department after 5 pm on the same day in both long-stay (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.17–1.48) and short-stay patients (OR 1.22, 95% CI 1.07–1.39). Stronger associations were observed for less acute visits to the emergency department. No associations were observed for other types of home care visits.

INTERPRETATION:

Patients receiving home care were more likely to visit the emergency department during the evening on days they received a nursing visit. The mechanism of the association between home care visits and same-day emergency department use and the extent to which same-day emergency department visits could be prevented or diverted require additional investigation.

[Perspectives] Stories of shame

The American physician and writer, Danielle Ofri, tells the story of a near fatal mistake that she made at the beginning of the second year of her residency. A patient was brought to the emergency room in a diabetic coma, and although her initial management was fine, Ofri then made an error and “proceeded to nearly kill…[the] patient”. Recognising her predicament, she called for senior assistance. When an explanation was demanded of her performance, Ofri’s words dried up. Humiliation set in as she was questioned in front of her intern: “I could almost feel myself dying away on the spot.

[Comment] The Lancet Commission on malaria eradication

20 years ago, infectious diseases dominated the global health agenda. Policy makers, researchers, implementers, and donors united in the fight against infectious diseases, creating the Millennium Development Goals, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi, the Vaccine Alliance, the US President’s Emergency Plan For AIDS Relief (PEPFAR), the Roll Back Malaria Partnership, the Multilateral Initiative on Malaria (MIM),1 and more. Tremendous progress was made. Malaria benefited spectacularly and there has been a 47% reduction in global deaths from the disease since 2000.

[Editorial] UK COPD treatment: failing to progress

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality in the world today. More than a million British people lived with diagnosed COPD in the UK in 2014–15, or just under 2% of the population. COPD admissions to emergency services in the UK are on the rise, but, access to treatments shown to reduce patients’ time spent in hospital is still woefully inadequate.

[Perspectives] A neurologist’s detective stories

Western medicine is organised into silos. Faced with a patient requiring specialist advice, a general practitioner or emergency doctor has to make a call about where to direct them. Sometimes, the right clinical destination is obvious: a compound thigh fracture will always need an orthopaedic surgeon. But many patients fall foul of this rigid system. An individual complaining of dizziness might get bounced from ENT, to cardiology, to neurology, to psychiatry before achieving a diagnosis.

Young Aussies and Bupa? Why bother?

BY ALEX FARRELL, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION and JOEL SELBY, AMSA PUBLIC RELATIONS OFFICER

It will not be surprising to readers that the changes recently announced by Bupa have caused anxiety among patients and outrage among the medical community in equal measure. However, one aspect rarely mentioned is the fact that young Australians are particularly short-changed by private health insurance.

Medical students experienced the Bupa changes from two perspectives – as young Australians long disillusioned by what the private health sector can offer them; and as future doctors despairing for what this means for the workforce we will inherit.

According to the APRA statistics for September-December 2017, the largest net drop in coverage was for people aged 25-29. A total of 11,170 people in this age bracket gave their funds the flick. A further 10,505 people aged 30-34 did the same.

In 2017, Choice, an independent consumer advocacy group, made waves by claiming that singles under 30 earning under $90,000 annually are better off without insurance at all.

Of course young people aren’t buying into private health insurance. Frustration with ‘junk policies’ is at an all-time high, with students tired of paying for schemes that don’t translate into coverage for the essential health costs that they will actually face over their lives.

Young people were already leaving their funds in droves when it was announced that from April premiums would rise by 3.95 per cent, far above the inflation rate and average annual growth of wages. Faced with paying more for the same policy, it would have been fair to wonder, why would any young Australian bother with private health cover at all?

For many, the last straw has come as Bupa, the largest private health insurer in Australia, announced its intention to downgrade policies, introduce exclusions, no longer provide a no-gap benefit in public emergency admissions, and only pay its higher-gap scheme benefit in Bupa-contracted hospitals.

For medical students, this is a double-edged sword. Not only do the Bupa changes affect them personally, now they will also reduce their ability to function as service providers in a healthcare system that provides universal access, regardless of means.

Bupa’s claims that it is not trying to dominate the insurance marketplace ring hollow. Like Henry Ford’s claim that a customer could have any colour they like as long as it’s black, it is ironic that Bupa claims its customers can have as much choice with no-gap coverage as ever, as long as they visit a Bupa-contracted facility. If Bupa succeeds in this venture, other insurers will follow, and the consumer choice that we rightfully value will be up for sale.

Private health insurance is a crucial part of the medical system, and provides much-needed relief on the public sector, but customers, particularly sick patients, deserve a fair go. There is a reason that comparisons to an Americanised healthcare system are rejected so strongly by Bupa’s lobbyists – the Australian public knows instinctively that commercialised, managed care will benefit no-one but the insurers themselves.

Graduate supply and public hospital funding – when will Government get this the right way around?

BY DR RODERICK McRAE, CHAIR, AMA COUNCIL OF PUBLIC HOSPITAL DOCTORS

As I write, Victorian salaried doctors are voting on its recommended Enterprise Bargaining Agreement, and other jurisdictions are in advanced negotiations in the new industrial relations frameworks. Relevant reports will follow.

My attendance at the sobering March 3 AMA Workforce and Training Summit convened in Melbourne, together with inspection of AMA’s 2018 Public Hospital Report Card, explains my continued exasperation at the consistent failure of Government to introduce realistic, necessary policy responses that deal with the now clearly apparent multiple medical training pipeline obstacles and poor public hospital access. Currently we have too much medical graduate supply and insufficient funding for appropriately training our junior colleagues in a manner that will meaningfully lead to reasonable public access to public hospital services.

The Summit attitude was constructive with about 80 national stakeholders combining to produce many broadly supported actions which AMA can prosecute. The Summit’s challenge was to consider what measures are needed further ‘downstream’ in training provision to ensure sufficient high quality training places in all medical specialties as they are needed for community benefit. While I fear the problems we now face are actually fast becoming too entrenched to solve, the Summit made it apparent that the medical profession is looking to the AMA, and within it your Council of Public Hospitals Doctors (CPHD), to lead the case for major reform. Accordingly, CPHD will be guided by the outcome strategies of the Summit, and will press to further inform and influence our health policy makers.

Two certain consensus points emerged from the Summit: stop opening new medical schools, and start rationalising resources towards regions and specialties where they are most needed. Government has regularly failed to fully listen to AMA’s advance warnings that there is real structural constraint to training capacity and that substantial ongoing investment is necessary to maintain training standards. Additionally, we need to urgently find sustainable, equitable paths to tackle the maldistribution of doctors (particularly across rural settings) and the shortages or bottlenecks arising in some craft areas.

I observe that it was AMA advocacy that achieved for most medical school graduates (and including many International Medical Graduates) guaranteed internship after graduation when, incredibly, Government had not actually originally factored this in to its expansion decision. Just another Federal/State divide. And, let’s not forget, the massive increase of new graduates doesn’t actually have true tsunami characteristics of quick destruction by ingress then receding as fast as it came, enabling an early, planned, rebuild. Instead, there is actually a permanent rising of the water table, overwhelming teaching infrastructure capacity, which means patients in public hospital beds.

The point is, we are graduating medical students in numbers far in excess of the OECD average without ensuring the adequate provision of the essential training places, both prevocational and specialist. This is at the same time that Commonwealth funding investment is not keeping pace with population growth. Any economist would reel.

In my December 2017 Australian Medicine piece, I discussed the ‘doing more with less’ implications of the Commonwealth financially penalising public hospitals who report acquired conditions, sentinel events and avoidable readmissions, otherwise known as possible healthcare outcomes (as if we are exercising choice to not provide optimum care now!). Added to that is the idea of penalising ‘low value care’ based on what are imposed and unsophisticated definitions, all with the aim of minimising financing, and a country mile from favourable health outcomes. This Commonwealth approach is in conjunction with them not offering any additional long term hospital funding via its 2020 State Agreement.

So, we have no additional funding despite AMA’s 2018 Public Hospital Report Card establishing there has been a 3.3 percent year-on-year average increase in separations (that’s called increased productivity), that one third of urgent emergency department patients are not seen within the recommended 30 minutes and that most States’ urgent elective surgery is not performed within the 90 day clinically indicated timeframe (that’s called increased demand). Don’t get me started on the sometimes years of a patient waiting to be seen in outpatients before actually being counted on an elective waiting list! And they want to claw back already insufficient funding when a complication happens. That economic management is called madness. If only health care really was like slapping a motor vehicle together on a production line; but it just is not.

The Summit’s Report will help us work together to develop initiatives to build a sustainable, well-trained, well-qualified and accessible medical workforce. The AMA’s Report Card is true evidence-based advocacy about hospital performance and the need for Government funding support to improve public access. Both suggest the public health climate is ominous with Government offering less funding but at the same time pressing for improved outcomes and offering more graduates but with no clear, coordinated, training pipeline management. Government must listen to us because of the implications for the community’s fair access to appropriate public hospital services, and for the career aspirations of our best and brightest.

[Comment] Offline: The Palestinian health predicament worsens

The United Nations Relief and Works Agency (UNRWA), which administers health services to 5·3 million Palestinian refugees through 143 primary health facilities, is in acute crisis. After President Trump cut almost US$300 million from UNRWA’s 2018 budget, services will run out of money by the end of May. Irrespective of one’s views about the complex politics of the Middle East, America’s decision to threaten the provision of basic health care to millions of dependent people seems utterly cruel. This emergency was a major theme of last week’s annual Lancet Palestinian Health Alliance (LPHA) scientific meeting, held in Beirut, Lebanon.

[Comment] Atraumatic lumbar puncture needles: practice needs to change

Lumbar puncture is a procedure used to obtain cerebrospinal fluid for diagnostic or therapeutic purposes and spinal anaesthesia. A retrospective study1 showed that in 2014, lumbar puncture was done in 1·4% of patients admitted to hospital and 0·8% of patients who were admitted to Accident and Emergency departments in France. Extrapolating these figures to the National Health Service Accident and Emergency attendance data indicates that more than 160 000 lumbar punctures are done in the UK annually.

Aged Care Commission needed to address workforce issues

The AMA has made a detailed submission to the Government’s Aged Care Workforce Strategy Taskforce, arguing that the aged care workforce does not have the capability, capacity and connectedness needed to provide quality care to older people.

It calls for an Aged Care Commission to be introduced.

Australia has an ageing population that has multiple chronic and complex medical conditions, but older people face major barriers in accessing appropriate and timely medical care.

Medical practitioners must be supported by the Government and aged care providers to enhance and facilitate much needed access to medical care for people living in residential aged care facilities.

The submission argues that aged care providers need to be supported to ensure access to an appropriate quantity of well-trained staff who work in a rewarding environment with a manageable workload.

“This would ensure older people’s care is not neglected due to shortages of appropriate staff,” it states.

An Aged Care Commission could streamline the aged care system and to help ensures there is an adequate supply of appropriate, well-trained staff to meet the demand of holistic care to a multicultural, ageing population.

An Aged Care Commission would also ensure the aged care workforce has clear roles and responsibilities.

“Australia has an ageing population that is experiencing chronic, complex medical conditions that require more medical attention than ever before,” the submission states.

“For example, 53 per cent of residents in Residential Aged Care Facilities (RACFs) have dementia. This proportion will continue to grow over time, with projections reaching up to 1,100,890 people with dementia by 2056, which is estimated to cost Australia $36.85 billion by the same year.

“A recent study identified that residents of RACFs with dementia had direct health and residential care costs of $88 000 per year. Currently, the aged care system as a whole, and its workforce, does not have the capacity or capability to adequately deal with this growing, ageing population.”

The aged care system needs a strategy, the submission states, to ensure the workforce is appropriate to meet the demands of older people in the future. In order to improve the quality of the aged care workforce, the following is required:

An overarching, independent, Aged Care Commission that provides a clear, well communicated, governance hierarchy that brings leadership and accountability to the aged care system;
Medical practitioners need to be recognised and supported as a crucial part of the aged care workforce to improve medical access, care, and outcomes for older people; and
Aged care needs funding for the significant recruitment and retention of, and support for, nursing staff and carers, specifically trained in dealing with the issues that older people face.

Care of an older person involves a diverse range of professions. All providers of aged care services need to collaborate together to ensure the optimal level of care for the older person. The strategy will be able to provide an ultimate goal for the whole aged care workforce, which should include access to the older person in order for each workforce profession to be able to provide quality care for that older person.

There needs to be a focus on prevention to ensure older people remain healthy for as long as possible to remain in their own home, the submission states, but also to reduce demand and pressure on the aged care workforce.

“Medical practitioners, in particular GPs, regularly incorporate prevention methods as part of providing holistic health and medical care,” it says.

“This includes immunisation, screening for diseases, providing education and counselling to their patient, and also referring the patient to a specialist or allied health professional if required. It is therefore imperative that older people have access to a GP and other services provided by health professionals.”

In its submission, the AMA stresses that the current policy settings do not support GPs visiting RACFs, working after hours, or being available to answer telephone concerns about their patients.

“Our members report that continuity of care goes generally unacknowledged in many RACFs and a resident’s care management plan is not well known,” it says.

“This creates an environment where the default step for RACF staff may be to refer the patient to a hospital emergency department (ED). In a study of 2880 residents of RACFs presented to the ED, one third of presentations could have been avoided by incorporating primary care services.

“Reasons for decisions to transfer residents to an ED include limited skilled staff, delays in GP consultations, and a lack of suitable equipment.”

Medical practitioners also need to be supported within the broader health care system to provide high quality care in RACFs. For example, by local hospitals providing secondary referral, timely specialist opinion, specialist services and rapid referral pathways to advice and services.

Older people are often burdened with complex and multiple medical disorders that requires the regular attention of medical practitioners, quality nursing care and allied health care professionals.

Embracing Information and Communication Technology (ICT) potentially has huge benefits for the aged care sector. It can increase communication between healthcare providers, reduce administrative burden, and assist to improve the health and independence of older people.

Aged care providers require improved ICT systems that are interoperable with the My Health Record, in particular its Medication Overview feature. This would ensure medical health professionals have the tools in place to access all relevant medical information with all relevant stakeholders to improve prescribing and to reduce the risk of adverse reactions and interactions between medications.

“Although working with older people is generally a rewarding experience, it comes with multiple challenges,” the submission states.

“For example, older people can be highly reliant on an aged care worker, and many have behavioural conditions that make day-to-day tasks difficult, and sometimes dangerous for the carer to carry out if the older person’s mental health is not appropriately managed.

“Carers are known to have high rates of moderate stress and depression. The health and wellbeing of aged care staff must be considered for the wellbeing of the workers, and so this stressful environment does not deter people from wanting to work in the aged care sector, or force existing workers to leave.”

Many of the issues outlined in the submission can be rectified by improving the capability, capacity and connectedness of the aged care workforce. Currently, this workforce is not adequately trained to be able to care for older Australians, as older peoples’ care needs are growing in both complexity and volume.

In addition, although medical practitioners are well-equipped to provide quality medical care to residents living in RACFs, they are not adequately supported or remunerated to do so due to the range of issues described above. This has resulted in an unnecessary barrier to quality medical services for RACF residents.

“The aged care workforce needs clear leadership and accountability, which an Aged Care Commission could provide,” the statement says.

“Many aged care governance (and workforce) issues described above have already been addressed in recommendations to the Government as a result of the multiple aged care reviews. Now is the time to act on these recommendations to prevent more unacceptable examples of neglect and bad quality care in RACFs, and to give people living in RACFs the quality of life that they deserve.”

The full submission can be viewed at: ausmed/aged-care-commission-needed-address-workforce-…

CHRIS JOHNSON