Browsing by Subject "Health Services for the Aged"

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    Changes in hospitalisation and surgical procedures among the oldest-old: a follow-up study of the entire Danish 1895 and 1905 cohorts from ages 85 to 99 years.
    (Age Ageing, 2013-07) Oksuzyan, Anna; Jeune, Bernard; Juel, Knud; Vaupel, James W; Christensen, Kaare
    OBJECTIVE: to examine whether the Danish 1905 cohort members had more active hospital treatment than the 1895 cohort members from ages 85 to 99 years and whether it results in higher in-hospital and post-operative mortality. METHODS: in the present register-based follow-up study the complete Danish birth cohorts born in 1895 (n = 12,326) and 1905 (n = 15,477) alive and residing in Denmark at the age of 85 were followed from ages 85 to 99 years with regard to hospitalisations and all-cause and cause-specific surgical procedures, as well as in-hospital and post-operative mortality. RESULTS: the 1905 cohort members had more frequent hospital admissions and operations, but they had a shorter length of hospital stay than the 1895 cohort at all ages from 85 to 99 years. The increase in primary prosthetic replacements of hip joint was observed even within the 1895 cohort: no patients were operated at ages 85-89 years versus 2.2-3.6% at ages 95-99 years. Despite increased hospitalisation and operation rates, there was no increase in post-operative and in-hospital mortality rates in the 1905 cohort. These patterns were similar among men and women. CONCLUSIONS: the observed patterns are compatible with more active treatment of the recent cohorts of old-aged persons and reduced age inequalities in the Danish healthcare system. No increase in post-operative mortality suggests that the selection of older patients eligible for a surgical treatment is likely to be based on the health status of old-aged persons and the safety of surgical procedures rather than chronological age.
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    Does Medicaid pay more to a program of all-inclusive care for the elderly (PACE) than for fee-for-service long-term care?
    (J Gerontol A Biol Sci Med Sci, 2013-01) Wieland, Darryl; Kinosian, Bruce; Stallard, Eric; Boland, Rebecca
    BACKGROUND: In rebalancing from nursing homes (NHs), states are increasing access of NH-certified dually eligible (Medicare/Medicaid) patients to community waiver programs and Programs of All-Inclusive Care for the Elderly (PACE). Prior evaluations suggest Medicaid's PACE capitation exceeds its spending for comparable admissions in alternative care, although the latter may be underestimated. We test whether Medicaid payments to PACE are lower than predicted fee-for-service outlays in a long-term care admission cohort. METHODS: Using grade-of-membership methods, we model health deficits for dual eligibles aged 55 or more entering waiver, PACE, and NH in South Carolina (n = 3,988). Clinical types, membership vectors, and program type prevalences are estimated. We calculate a blend, fitting PACE between fee-for-service cohorts, whose postadmission 1-year utilization was converted to attrition-adjusted outlays. PACE's capitation is compared with blend-based expenditure predictions. RESULTS: Four clinical types describe population health deficits/service needs. The waiver cohort is most represented in the least impaired type (1: 47.1%), NH entrants in the most disabled (4: 38.5%). Most prevalent in PACE was a dementia type, 3 (32.7%). PACE's blend was waiver: 0.5602 (95% CI: 0.5472, 0.5732) and NH: 0.4398 (0.4268, 0.4528). Average Medicaid attrition-adjusted 1-year payments for waiver and NH were $4,177 and $77,945. The mean predicted cost for PACE patients in alternative long-term care was $36,620 ($35,662 and $37,580). PACE's Medicaid capitation was $27,648-28% below the lower limit of predicted fee-for-service payments. CONCLUSIONS: PACE's capitation was well under outlays for equivalent patients in alternative care-a substantial savings for Medicaid. Our methods provide a rate-setting element for PACE and other managed long-term care.
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    Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: based on the AOSpine North America geriatric odontoid fracture study.
    (Spine, 2013-12) Smith, Justin S; Kepler, Christopher K; Kopjar, Branko; Harrop, James S; Arnold, Paul; Chapman, Jens R; Fehlings, Michael G; Vaccaro, Alexander R; Shaffrey, Christopher I

    Study design

    Subgroup analysis of a prospective multicenter study.

    Objective

    Outcome analysis of nonoperatively treated elderly patients with type II odontoid fractures, including assessment of consequence of a fracture nonunion.

    Summary of background data

    Odontoid fractures are among the most common fractures in the elderly, and controversy exists regarding treatment.

    Methods

    Subgroup analysis of a prospective multicenter study of elderly patients (≥65 yr) with type II odontoid fracture. Neck Disability Index and Short-Form 36 (SF-36) version 2 were collected at baseline and 6 and 12 months. Fifty-eight (36.5%) of the 159 patients were treated nonoperatively.

    Results

    Of the 58 patients initially treated nonoperatively, 8 died within 90 days and were excluded. Of the remaining 50 patients, 11 (22.0%) developed nonunion, with 7 (63.6%) requiring surgery. Four of the 39 (10.3%) patients classified as having "successful union" required surgery due to late fracture displacement. Thus, 15 (30.0%) patients developed primary or secondary nonunion and 11 (22.0%) required surgery. The overall 12-month mortality was 14.0% (nonunion = 2, union = 5; P= 0.6407). For union and nonunion groups, Neck Disability Index and SF-36 version 2 declined significantly at 12 months compared with preinjury values (P< 0.05), except for SF-36 version 2 Physical Functioning (P= 0.1370). There were no significant differences in outcome parameters based on union status at 12 months (P> 0.05); however, it is important to emphasize that the 12-month outcomes for the nonunion patients reflect the status of the patient after delayed surgical treatment in the majority of these cases.

    Conclusion

    Nonoperative treatment for type II odontoid fracture in the elderly has high rates of nonunion and mortality. Patients with nonunion did not report worse outcomes compared with those who achieved union at 12 months; however, the majority of patients with nonunion required delayed surgical treatment. These findings may prove useful for patients who are not surgical candidates or elect for nonoperative treatment.

    Level of evidence

    2.
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    Five-year survival in a Program of All-inclusive Care for Elderly compared with alternative institutional and home- and community-based care.
    (J Gerontol A Biol Sci Med Sci, 2010-07) Wieland, Darryl; Boland, Rebecca; Baskins, Judith; Kinosian, Bruce
    BACKGROUND: Community-based services are preferred to institutional care for people requiring long-term care (LTC). States are increasing their Medicaid waiver programs, although Program of All-Inclusive Care For Elderly (PACE)-prepaid, community-based comprehensive care-is available in 31 states. Despite emerging alternatives, little is known about their comparative effectiveness. METHODS: For a two-county region of South Carolina, we contrast long-term survival among entrants (n = 2040) to an aged and disabled waiver program, PACE, and nursing homes (NHs), stratifying for risk. Participants were followed for 5 years or until death; those lost to follow-up or surviving less than 5 years as on August 8, 2005 were censored. Analyses included admission descriptive statistics and Kaplan-Meier curves. To address cohort risk imbalance, we employed an established mortality risk index, which showed external validity in waiver, PACE, and NH cohorts (log-rank tests = 105.42, 28.72, and 52.23, respectively, all p < .001; c-statistics = .67, .58, .65, p < .001). RESULTS: Compared with waiver (n = 1,018) and NH (n = 468) admissions, PACE participants (n = 554) were older, more cognitively impaired, and had intermediate activities of daily living dependency. PACE mortality risk (72.6% high-to-intermediate) was greater than in waiver (58.8%), and similar to NH (71.6%). Median NH survival was 2.3 years. Median PACE survival was 4.2 years versus 3.5 in waiver (unstratified, log rank = .394; p = .53), but accounting for risk, PACE's advantage is significant (log rank = 5.941 (1); p = .015). Compared with waiver, higher risk admissions to PACE were most likely to benefit (moderate: PACE median survival = 4.7 years vs waiver 3.4; high risk: 3.0 vs 2.0). CONCLUSION: Long-term outcomes of LTC alternatives warrant greater research and policy attention.
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    From Hospital to Home: Impact of Transitional Care on Cost, Hospitalisation and Mortality.
    (Annals of the Academy of Medicine, Singapore, 2019-10) Ang, Yan Hoon; Ginting, Mimaika Luluina; Wong, Chek Hooi; Tew, Chee Wee; Liu, Chang; Sivapragasam, Nirmali Ruth; Matchar, David Bruce
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    Future requirements for and supply of ophthalmologists for an aging population in Singapore.
    (Hum Resour Health, 2015-11-17) Ansah, John P; De Korne, Dirk; Bayer, Steffen; Pan, Chong; Jayabaskar, Thiyagarajan; Matchar, David B; Lew, Nicola; Phua, Andrew; Koh, Victoria; Lamoureux, Ecosse; Quek, Desmond
    BACKGROUND: Singapore's population, as that of many other countries, is aging; this is likely to lead to an increase in eye diseases and the demand for eye care. Since ophthalmologist training is long and expensive, early planning is essential. This paper forecasts workforce and training requirements for Singapore up to the year 2040 under several plausible future scenarios. METHODS: The Singapore Eye Care Workforce Model was created as a continuous time compartment model with explicit workforce stocks using system dynamics. The model has three modules: prevalence of eye disease, demand, and workforce requirements. The model is used to simulate the prevalence of eye diseases, patient visits, and workforce requirements for the public sector under different scenarios in order to determine training requirements. RESULTS: Four scenarios were constructed. Under the baseline business-as-usual scenario, the required number of ophthalmologists is projected to increase by 117% from 2015 to 2040. Under the current policy scenario (assuming an increase of service uptake due to increased awareness, availability, and accessibility of eye care services), the increase will be 175%, while under the new model of care scenario (considering the additional effect of providing some services by non-ophthalmologists) the increase will only be 150%. The moderated workload scenario (assuming in addition a reduction of the clinical workload) projects an increase in the required number of ophthalmologists of 192% by 2040. Considering the uncertainties in the projected demand for eye care services, under the business-as-usual scenario, a residency intake of 8-22 residents per year is required, 17-21 under the current policy scenario, 14-18 under the new model of care scenario, and, under the moderated workload scenario, an intake of 18-23 residents per year is required. CONCLUSIONS: The results show that under all scenarios considered, Singapore's aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists.
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    Living Arrangements of Older Adults and COVID-19 Risk: It Is Not Just Nursing Homes.
    (Journal of the American Geriatrics Society, 2020-07) Coe, Norma B; Van Houtven, Courtney Harold
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    Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology.
    (BJU Int, 2010-08) Droz, Jean-Pierre; Balducci, Lodovico; Bolla, Michel; Emberton, Mark; Fitzpatrick, John M; Joniau, Steven; Kattan, Michael W; Monfardini, Silvio; Moul, Judd W; Naeim, Arash; van Poppel, Hendrik; Saad, Fred; Sternberg, Cora N
    Prostate cancer is the most prevalent cancer in men and predominantly affects older men (aged >or=70 years). The median age at diagnosis is 68 years; overall, two-thirds of prostate cancer-related deaths occur in men aged >or=75 years. With the exponential ageing of the population and the increasing life-expectancy in developed countries, the burden of prostate cancer is expected to increase dramatically in the future. To date, no specific guidelines on the management of prostate cancer in older men have been published. The International Society of Geriatric Oncology (SIOG) conducted a systematic bibliographic search based on screening, diagnostic procedures and treatment options for localized and advanced prostate cancer, to develop a proposal for recommendations that should provide the highest standard of care for older men with prostate cancer. The consensus of the SIOG Prostate Cancer Task Force is that older men with prostate cancer should be managed according to their individual health status, which is mainly driven by the severity of associated comorbid conditions, and not according to chronological age. Existing international recommendations (European Association of Urology, National Comprehensive Cancer Network, and American Urological Association) are the backbone for localized and advanced prostate cancer treatment, but need to be adapted to patient health status. Based on a rapid and simple evaluation, patients can be classified into four different groups: 1, 'Healthy' patients (controlled comorbidity, fully independent in daily living activities, no malnutrition) should receive the same treatment as younger patients; 2, 'Vulnerable' patients (reversible impairment) should receive standard treatment after medical intervention; 3, 'Frail' patients (irreversible impairment) should receive adapted treatment; 4, Patients who are 'too sick' with 'terminal illness' should receive only symptomatic palliative treatment.
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    [More people live to be very old and with a better functioning].
    (Ugeskr Laeger, 2013-10-07) Christensen, Kaare; Jeune, Bernard; Andersen-Ranberg, Karen; Vaupel, James W
    Death rates for 80+-year-olds are now half of what they were after WWII. The chance of living past 90 years has gone up by roughly 30% per decade for people born in Denmark in 1895, 1905, and 1915 - and the later cohorts are functioning better physically and cognitively. Centenarians are on average functioning physically and cognitively as well as 92-93-year-olds due to selective mortality. A steep increase in the frequency of hospitalization and surgical procedure among 85-100-year-olds is occurring, but there is a lack of knowledge about treatment effects and side effects among the oldest-old.
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    Projecting the number of older singaporeans with activity of daily living limitations requiring human assistance through 2030.
    (Annals of the Academy of Medicine, Singapore, 2014-01) Thompson, James; Malhotra, Rahul; Love, Sean; Ostbye, Truls; Chan, Angelique; Matchar, David

    Introduction

    In the context of rapid population ageing and the increase in number of activity of daily living (ADL) limitations with age, the number of older persons requiring human assistance in Singapore is likely to grow. To promote informed planning for the needs of these elderly, we project the number of resident Singaporeans 60 years of age and older with 1 or more ADL limitations requiring human assistance through 2030.

    Materials and methods

    The proportion of community-dwelling older adults with ADL limitations requiring human assistance, stratified by gender and age group, was calculated utilising a recent nationally-representative survey of older Singaporeans. The proportion of older adults in nursing homes with ADL limitations was estimated based on available literature. Together, these prevalence estimates were applied to a simulation of the future population of older adults in Singapore to derive an estimate of the number of individuals with ADL limitations requiring human assistance through 2030.

    Results

    By 2030, the number of resident Singaporeans aged 60 years or older with 1 or more ADL limitations requiring human assistance is projected to be 82,968 persons (7% of the total population aged 60 years or older). Of this number, 38,809 (47%) are estimated to have 1 or 2 ADL limitations, and 44,159 (53%) are estimated to have 3 or more.

    Conclusion

    The number of elderly Singaporeans with activity limitations is expected grow rapidly from 31,738 in 2010 to 82,968 in 2030. Estimates of the number of older individuals with ADL limitations requiring human assistance are of value for policymakers as well as acute and long-term care capacity planners as they seek to meet demand for health and social services in Singapore.
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    The AOSpine North America Geriatric Odontoid Fracture Mortality Study: a retrospective review of mortality outcomes for operative versus nonoperative treatment of 322 patients with long-term follow-up.
    (Spine, 2013-06) Chapman, Jens; Smith, Justin S; Kopjar, Branko; Vaccaro, Alexander R; Arnold, Paul; Shaffrey, Christopher I; Fehlings, Michael G
    STUDY DESIGN: Retrospective, multicenter cohort study. OBJECTIVE: Assess for differences in short- and long-term mortality between operative and nonoperative treatment for elderly patients with type II odontoid fractures. SUMMARY OF BACKGROUND DATA: There is controversy regarding whether operative or nonoperative management is the best treatment for elderly patients with type II odontoid fractures. METHODS: This is a retrospective study of consecutive patients aged 65 years or older with type II odontoid fracture from 3 level I trauma centers from 2003-2009. Demographics, comorbidities, and treatment were abstracted from medical records. Mortality outcomes were obtained from medical records and a public database. Hazard ratios (HRs) and 95% confidence intervals (CI) were calculated. RESULTS: A total of 322 patients were included (mean age, 81.8 yr; range, 65.0-101.5 yr). Compared with patients treated nonoperatively (n = 157), patients treated operatively (n = 165) were slightly younger (80.4 vs. 83.2 yr, P = 0.0014), had a longer hospital (15.0 vs. 7.4 d, P < 0.001) and intensive care unit (1.5 vs. 1.1 d, P = 0.008) stay, and were more likely to receive a feeding tube (18% vs. 5%, P = 0.0003). Operative and nonoperative treatment groups had similar sex distribution (P = 0.94) and Charlson comorbidity index (P = 0.11). Within 30 days of presentation, 14% of patients died, and at maximal follow-up (average = 2.05 yr; range = 0 d-7.02 yr), 44% had died. On multivariate analysis, nonoperative treatment was associated with higher 30-day mortality (HR = 3.00, 95% CI = 1.51-5.94, P = 0.0017), after adjusting for age (HR = 1.10, 95% CI = 1.05-1.14; P < 0.0001), male sex (P = 0.69), and Charlson comorbidity index (P = 0.16). At maximal follow-up, there was a trend toward higher mortality associated with nonoperative treatment (HR = 1.35, 95% CI = 0.97-1.89, P = 0.079), after adjusting for age (HR = 1.07, 95% CI = 1.05-1.10; P < 0.0001), male sex (HR = 1.55, 95% CI = 1.10-2.16; P = 0.012), and Charlson comorbidity index (HR = 1.28, 95% CI = 1.16-1.40; P < 0.0001). CONCLUSION: Surgical treatment of type II odontoid fracture in this elderly population did not negatively impact survival, even after adjusting for age, sex, and comorbidities. The data suggest a significant 30-day survival advantage and a trend toward improved longer-term survival for operatively treated over nonoperatively treated patients. LEVEL OF EVIDENCE: 4.
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    Where to go if not the hospital? Reviewing geriatric bed utilization in an acute care hospital in Singapore.
    (Geriatrics & gerontology international, 2017-10) Zhou, Ke; Vidyarthi, Arpana R; Wong, Chek Hooi; Matchar, David

    Aim

    Singapore is one of the fastest-aging countries in the world, and the demand for acute hospital care for older adults is expected to triple in the next 25 years. Hence, it is crucial to understand the opportunities in reducing potentially avoidable bed days (PABD), which are days spent in acute hospitals delivering only non-acute services. We aimed to access the prevalence, causes and consequences of PABD among geriatric patients.

    Methods

    We examined all hospitalizations from 1 August through 31 December 2013 in the geriatric wards of an acute hospital in Singapore. PABD were identified using a modified Appropriateness Evaluation Protocol. Non-acute services were classified as subacute care, rehabilitative care, long-term care or social care. Hospitalization patterns were determined based on the presence or absence of non-acute services, and multinomial logistic regression was used to determine predictors of different patterns.

    Results

    Of the 273 bed days used by 254 patients, 49% were potentially avoidable. The most common non-acute services provided were rehabilitative care (19%), subacute care (12%) and long-term care (8%). New acute issues arose after the admission conditions subsided in 2.4% of hospitalizations, 61% of which were nosocomial infections. Being socially at risk as assessed on admission predicted the development of new acute issues (sensitivity = 62%; specificity = 88%).

    Conclusions

    In the present study, almost half of the bed days were potentially avoidable. New acute issues can arise after PABD, which are dangerous to these frail older adults. Proactive discharge planning and increasing access to intermediate and long-term care services are required to reduce PABD. Geriatr Gerontol Int 2017; 17: 1575-1583.