Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort
Identifieur interne : 002237 ( Ncbi/Merge ); précédent : 002236; suivant : 002238Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort
Auteurs : Luke Mondor [Canada] ; Colleen J. Maxwell [Canada] ; David B. Hogan [Canada] ; Susan E. Bronskill [Canada] ; Andrea Gruneir [Canada] ; Natasha E. Lane [Canada] ; Walter P. Wodchis [Canada]Source :
- PLoS Medicine [ 1549-1277 ] ; 2017.
Abstract
For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.
A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC.
Multimorbidity was highly prevalent, with 35% (
Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes.
Url:
DOI: 10.1371/journal.pmed.1002249
PubMed: 28267802
PubMed Central: 5340355
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Maxwell</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute for Clinical Evaluative Sciences, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Health System Performance Research Network, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Health System Performance Research Network, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff003"><addr-line>School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>School of Pharmacy, University of Waterloo, Waterloo, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff004"><addr-line>School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="4"><nlm:aff id="aff005"><addr-line>Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Department of Community Health Sciences, University of Calgary, Calgary, Alberta</wicri:regionArea><orgName type="university">Université de Calgary</orgName><placeName><settlement type="city">Calgary</settlement><region type="state">Alberta</region></placeName></affiliation></author><author><name sortKey="Hogan, David B" sort="Hogan, David B" uniqKey="Hogan D" first="David B." last="Hogan">David B. Hogan</name><affiliation wicri:level="4"><nlm:aff id="aff005"><addr-line>Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Department of Community Health Sciences, University of Calgary, Calgary, Alberta</wicri:regionArea><orgName type="university">Université de Calgary</orgName><placeName><settlement type="city">Calgary</settlement><region type="state">Alberta</region></placeName></affiliation><affiliation wicri:level="4"><nlm:aff id="aff006"><addr-line>Division of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Division of Geriatric Medicine, University of Calgary, Calgary, Alberta</wicri:regionArea><orgName type="university">Université de Calgary</orgName><placeName><settlement type="city">Calgary</settlement><region type="state">Alberta</region></placeName></affiliation></author><author><name sortKey="Bronskill, Susan E" sort="Bronskill, Susan E" uniqKey="Bronskill S" first="Susan E." last="Bronskill">Susan E. Bronskill</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute for Clinical Evaluative Sciences, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Health System Performance Research Network, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Health System Performance Research Network, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="4"><nlm:aff id="aff007"><addr-line>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario</wicri:regionArea><orgName type="university">Université de Toronto</orgName><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName></affiliation></author><author><name sortKey="Gruneir, Andrea" sort="Gruneir, Andrea" uniqKey="Gruneir A" first="Andrea" last="Gruneir">Andrea Gruneir</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute for Clinical Evaluative Sciences, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff008"><addr-line>Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Department of Family Medicine, University of Alberta, Edmonton, Alberta</wicri:regionArea><wicri:noRegion>Alberta</wicri:noRegion></affiliation></author><author><name sortKey="Lane, Natasha E" sort="Lane, Natasha E" uniqKey="Lane N" first="Natasha E." last="Lane">Natasha E. Lane</name><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Health System Performance Research Network, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Health System Performance Research Network, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="4"><nlm:aff id="aff007"><addr-line>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario</wicri:regionArea><orgName type="university">Université de Toronto</orgName><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName></affiliation></author><author><name sortKey="Wodchis, Walter P" sort="Wodchis, Walter P" uniqKey="Wodchis W" first="Walter P." last="Wodchis">Walter P. Wodchis</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute for Clinical Evaluative Sciences, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="1"><nlm:aff id="aff002"><addr-line>Health System Performance Research Network, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Health System Performance Research Network, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation><affiliation wicri:level="4"><nlm:aff id="aff007"><addr-line>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario</wicri:regionArea><orgName type="university">Université de Toronto</orgName><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName></affiliation><affiliation wicri:level="1"><nlm:aff id="aff009"><addr-line>Toronto Rehabilitation Institute, Toronto, Ontario, Canada</addr-line></nlm:aff><country xml:lang="fr">Canada</country><wicri:regionArea>Toronto Rehabilitation Institute, Toronto, Ontario</wicri:regionArea><wicri:noRegion>Ontario</wicri:noRegion></affiliation></author></analytic><series><title level="j">PLoS Medicine</title><idno type="ISSN">1549-1277</idno><idno type="eISSN">1549-1676</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title><p>For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.</p></sec><sec id="sec002"><title>Methods and findings</title><p>A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC.</p><p>Multimorbidity was highly prevalent, with 35% (<italic>n</italic> = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72–2.05, <italic>p <</italic> 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51–1.77, <italic>p <</italic> 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07–1.16, <italic>p <</italic> 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03–1.11, <italic>p =</italic> 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, <italic>p =</italic> 0.566 for hospitalization and <italic>p =</italic> 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions.</p></sec><sec id="sec003"><title>Conclusions</title><p>Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Bauer, K" uniqKey="Bauer K">K Bauer</name></author><author><name sortKey="Schwarzkopf, L" uniqKey="Schwarzkopf L">L Schwarzkopf</name></author><author><name sortKey="Graessel, E" uniqKey="Graessel E">E Graessel</name></author><author><name sortKey="Holle, R" uniqKey="Holle R">R Holle</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Savva, Gm" uniqKey="Savva G">GM Savva</name></author><author><name sortKey="Stephan, Bcm" uniqKey="Stephan B">BCM Stephan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Whitmer, Ra" uniqKey="Whitmer R">RA Whitmer</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Med</journal-id><journal-id journal-id-type="iso-abbrev">PLoS Med</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosmed</journal-id><journal-title-group><journal-title>PLoS Medicine</journal-title></journal-title-group><issn pub-type="ppub">1549-1277</issn><issn pub-type="epub">1549-1676</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28267802</article-id><article-id pub-id-type="pmc">5340355</article-id><article-id pub-id-type="doi">10.1371/journal.pmed.1002249</article-id><article-id pub-id-type="publisher-id">PMEDICINE-D-16-03111</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Mental Health and Psychiatry</subject><subj-group><subject>Dementia</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Neurology</subject><subj-group><subject>Dementia</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Critical Care and Emergency Medicine</subject></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Care Facilities</subject><subj-group><subject>Hospitals</subject><subj-group><subject>Hospitalizations</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Care Providers</subject><subj-group><subject>Medical Doctors</subject><subj-group><subject>Physicians</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Population Groupings</subject><subj-group><subject>Professions</subject><subj-group><subject>Medical Doctors</subject><subj-group><subject>Physicians</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and places</subject><subj-group><subject>Geographical locations</subject><subj-group><subject>North America</subject><subj-group><subject>Canada</subject><subj-group><subject>Ontario</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Population Groupings</subject><subj-group><subject>Age Groups</subject><subj-group><subject>Elderly</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Health Care</subject><subj-group><subject>Health Care Facilities</subject><subj-group><subject>Hospitals</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and places</subject><subj-group><subject>Geographical locations</subject><subj-group><subject>North America</subject><subj-group><subject>Canada</subject></subj-group></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort</article-title><alt-title alt-title-type="running-head">Multimorbidity, healthcare utilization, and dementia</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Mondor</surname><given-names>Luke</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Maxwell</surname><given-names>Colleen J.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff003"><sup>3</sup></xref><xref ref-type="aff" rid="aff004"><sup>4</sup></xref><xref ref-type="aff" rid="aff005"><sup>5</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author"><name><surname>Hogan</surname><given-names>David B.</given-names></name><xref ref-type="aff" rid="aff005"><sup>5</sup></xref><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0002-7341-0655</contrib-id><name><surname>Bronskill</surname><given-names>Susan E.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff007"><sup>7</sup></xref></contrib><contrib contrib-type="author"><name><surname>Gruneir</surname><given-names>Andrea</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff008"><sup>8</sup></xref></contrib><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-1400-9068</contrib-id><name><surname>Lane</surname><given-names>Natasha E.</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff007"><sup>7</sup></xref></contrib><contrib contrib-type="author"><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-2494-7031</contrib-id><name><surname>Wodchis</surname><given-names>Walter P.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff007"><sup>7</sup></xref><xref ref-type="aff" rid="aff009"><sup>9</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Health System Performance Research Network, Toronto, Ontario, Canada</addr-line></aff><aff id="aff003"><label>3</label><addr-line>School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada</addr-line></aff><aff id="aff004"><label>4</label><addr-line>School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada</addr-line></aff><aff id="aff006"><label>6</label><addr-line>Division of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada</addr-line></aff><aff id="aff007"><label>7</label><addr-line>Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada</addr-line></aff><aff id="aff008"><label>8</label><addr-line>Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada</addr-line></aff><aff id="aff009"><label>9</label><addr-line>Toronto Rehabilitation Institute, Toronto, Ontario, Canada</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Brayne</surname><given-names>Carol</given-names></name><role>Academic Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>University of Cambridge, UNITED KINGDOM</addr-line></aff><author-notes><fn fn-type="COI-statement" id="coi001"><p>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p><list list-type="simple"><list-item><p><bold>Conceptualization:</bold> LM CJM.</p></list-item><list-item><p><bold>Data curation:</bold> LM.</p></list-item><list-item><p><bold>Formal analysis:</bold> LM.</p></list-item><list-item><p><bold>Funding acquisition:</bold> WPW.</p></list-item><list-item><p><bold>Methodology:</bold> LM CJM DBH SEB AG NEL WPW.</p></list-item><list-item><p><bold>Project administration:</bold> LM CJM WPW.</p></list-item><list-item><p><bold>Supervision:</bold> CJM WPW.</p></list-item><list-item><p><bold>Validation:</bold> LM CJM.</p></list-item><list-item><p><bold>Visualization:</bold> LM.</p></list-item><list-item><p><bold>Writing – original draft:</bold> LM.</p></list-item><list-item><p><bold>Writing – review & editing:</bold> LM CJM DBH SEB AG NEL WPW.</p></list-item></list></p></fn><corresp id="cor001">* E-mail: <email>colleen.maxwell@uwaterloo.ca</email></corresp></author-notes><pub-date pub-type="epub"><day>7</day><month>3</month><year>2017</year></pub-date><pub-date pub-type="collection"><month>3</month><year>2017</year></pub-date><volume>14</volume><issue>3</issue><elocation-id>e1002249</elocation-id><history><date date-type="received"><day>27</day><month>9</month><year>2016</year></date><date date-type="accepted"><day>2</day><month>2</month><year>2017</year></date></history><permissions><copyright-statement>© 2017 Mondor et al</copyright-statement><copyright-year>2017</copyright-year><copyright-holder>Mondor et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pmed.1002249.pdf"></self-uri><abstract><sec id="sec001"><title>Background</title><p>For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships.</p></sec><sec id="sec002"><title>Methods and findings</title><p>A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine–Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC.</p><p>Multimorbidity was highly prevalent, with 35% (<italic>n</italic> = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72–2.05, <italic>p <</italic> 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51–1.77, <italic>p <</italic> 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07–1.16, <italic>p <</italic> 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03–1.11, <italic>p =</italic> 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, <italic>p =</italic> 0.566 for hospitalization and <italic>p =</italic> 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions.</p></sec><sec id="sec003"><title>Conclusions</title><p>Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients’ risk of health outcomes.</p></sec></abstract><abstract abstract-type="toc"><p>In a retrospective analysis of routinely collected data, Luke Mondor and colleagues examine the associations between multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada.</p></abstract><abstract abstract-type="summary"><title>Author summary</title><sec id="sec004"><title>Why was this study done?</title><list list-type="bullet"><list-item><p>The co-occurrence of multiple chronic conditions in an individual (multimorbidity) has been linked to poor outcomes including increased hospital use, longer length of stays, and worse cognitive and physical functioning.</p></list-item><list-item><p>Particularly for community-residing older adults with dementia, multimorbidity can result in challenges to both self-care and provided care. Individuals with multimorbidity often receive care from multiple physicians across different care settings each year. This lack of physician continuity may lead to poorer quality of care and outcomes.</p></list-item><list-item><p>Important gaps exist in our understanding of the interplay between multimorbidity, health system use, and continuity of physician care specifically for individuals with dementia.</p></list-item><list-item><p>Our historical cohort study was designed to estimate the risk of acute care hospitalization and emergency department (ED) visit by level of multimorbidity (i.e., chronic disease burden) among persons with dementia in the community. We were especially interested in whether the risk of these health outcomes was lower for those with better continuity of physician care.</p></list-item></list></sec><sec id="sec005"><title>What did the researchers do and find?</title><list list-type="bullet"><list-item><p>We performed a retrospective cohort study of 30,112 home care clients with dementia in Ontario, Canada, using routinely collected health and clinical information linked at the individual level.</p></list-item><list-item><p>We defined the level of multimorbidity (i.e., chronic disease burden in addition to dementia diagnosis) based on a count of the presence of 16 common chronic conditions, and compared time, in days, from a health assessment to initial hospitalization (for any cause) and ED visit (not resulting in an inpatient stay) in persons with different multimorbidity levels. We accounted for other possible outcomes including death or placement in a long-term care facility.</p></list-item><list-item><p>We found that multimorbidity was highly prevalent in this population—89% of the cohort had been diagnosed with two or more conditions in addition to dementia.</p></list-item><list-item><p>In multivariable analyses, we found that the risk of hospitalization and ED visit increased with each higher level of multimorbidity.</p></list-item><list-item><p>These associations were comparable in clients with dementia who had high and low degrees of physician continuity. In other words, continuity of physician care did not modify the association between level of multimorbidity and the outcomes.</p></list-item></list></sec><sec id="sec006"><title>What do these findings mean?</title><list list-type="bullet"><list-item><p>Multimorbidity is the norm rather than the exception among older adults with dementia in the home care sector. This increased chronic disease burden is associated with a greater likelihood for costly hospital admissions and emergency visits.</p></list-item><list-item><p>With increases in life expectancy, improvements to disease detection, and a shift to community-based care, use of home care services and the prevalence of multimorbidity among older persons with dementia will likely rise. Data from this study may be useful in identifying at-risk individuals and prioritizing the deployment of limited healthcare resources.</p></list-item></list></sec></abstract><funding-group><award-group id="award001"><funding-source><institution-wrap><institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/501100000226</institution-id><institution>Ontario Ministry of Health and Long-Term Care</institution></institution-wrap></funding-source><award-id>06034</award-id><principal-award-recipient><contrib-id authenticated="true" contrib-id-type="orcid">http://orcid.org/0000-0003-2494-7031</contrib-id><name><surname>Wodchis</surname><given-names>Walter P.</given-names></name></principal-award-recipient></award-group><funding-statement>This research was supported by grants from the Ontario Ministry of Health and Long-Term Care (MOHLTC) and the Ontario SPOR Support Unit to the Health System Performance Research Network (HSPRN: fund #06034, recipient WPW), and by the Institute for Clinical Evaluative Sciences (ICES), which is also funded by an annual grant from the MOHLTC. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><fig-count count="1"></fig-count><table-count count="4"></table-count><page-count count="17"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>Data are available from the Institute for Clinical Evaluative Sciences in Toronto, Ontario (contact ICES Data and Analytic Services at <ext-link ext-link-type="uri" xlink:href="http://www.ices.on.ca/DAS">http://www.ices.on.ca/DAS</ext-link>) for researchers who meet the criteria for access to confidential data.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>Data are available from the Institute for Clinical Evaluative Sciences in Toronto, Ontario (contact ICES Data and Analytic Services at <ext-link ext-link-type="uri" xlink:href="http://www.ices.on.ca/DAS">http://www.ices.on.ca/DAS</ext-link>) for researchers who meet the criteria for access to confidential data.</p></notes></front></pmc><affiliations><list><country><li>Canada</li></country><region><li>Alberta</li><li>Ontario</li></region><settlement><li>Calgary</li><li>Toronto</li></settlement><orgName><li>Université de Calgary</li><li>Université de Toronto</li></orgName></list><tree><country name="Canada"><noRegion><name sortKey="Mondor, Luke" sort="Mondor, Luke" uniqKey="Mondor L" first="Luke" last="Mondor">Luke Mondor</name></noRegion><name sortKey="Bronskill, Susan E" sort="Bronskill, Susan E" uniqKey="Bronskill S" first="Susan E." last="Bronskill">Susan E. Bronskill</name><name sortKey="Bronskill, Susan E" sort="Bronskill, Susan E" uniqKey="Bronskill S" first="Susan E." last="Bronskill">Susan E. Bronskill</name><name sortKey="Bronskill, Susan E" sort="Bronskill, Susan E" uniqKey="Bronskill S" first="Susan E." last="Bronskill">Susan E. Bronskill</name><name sortKey="Gruneir, Andrea" sort="Gruneir, Andrea" uniqKey="Gruneir A" first="Andrea" last="Gruneir">Andrea Gruneir</name><name sortKey="Gruneir, Andrea" sort="Gruneir, Andrea" uniqKey="Gruneir A" first="Andrea" last="Gruneir">Andrea Gruneir</name><name sortKey="Hogan, David B" sort="Hogan, David B" uniqKey="Hogan D" first="David B." last="Hogan">David B. Hogan</name><name sortKey="Hogan, David B" sort="Hogan, David B" uniqKey="Hogan D" first="David B." last="Hogan">David B. Hogan</name><name sortKey="Lane, Natasha E" sort="Lane, Natasha E" uniqKey="Lane N" first="Natasha E." last="Lane">Natasha E. Lane</name><name sortKey="Lane, Natasha E" sort="Lane, Natasha E" uniqKey="Lane N" first="Natasha E." last="Lane">Natasha E. Lane</name><name sortKey="Maxwell, Colleen J" sort="Maxwell, Colleen J" uniqKey="Maxwell C" first="Colleen J." last="Maxwell">Colleen J. Maxwell</name><name sortKey="Maxwell, Colleen J" sort="Maxwell, Colleen J" uniqKey="Maxwell C" first="Colleen J." last="Maxwell">Colleen J. Maxwell</name><name sortKey="Maxwell, Colleen J" sort="Maxwell, Colleen J" uniqKey="Maxwell C" first="Colleen J." last="Maxwell">Colleen J. Maxwell</name><name sortKey="Maxwell, Colleen J" sort="Maxwell, Colleen J" uniqKey="Maxwell C" first="Colleen J." last="Maxwell">Colleen J. Maxwell</name><name sortKey="Maxwell, Colleen J" sort="Maxwell, Colleen J" uniqKey="Maxwell C" first="Colleen J." last="Maxwell">Colleen J. Maxwell</name><name sortKey="Mondor, Luke" sort="Mondor, Luke" uniqKey="Mondor L" first="Luke" last="Mondor">Luke Mondor</name><name sortKey="Wodchis, Walter P" sort="Wodchis, Walter P" uniqKey="Wodchis W" first="Walter P." last="Wodchis">Walter P. Wodchis</name><name sortKey="Wodchis, Walter P" sort="Wodchis, Walter P" uniqKey="Wodchis W" first="Walter P." last="Wodchis">Walter P. Wodchis</name><name sortKey="Wodchis, Walter P" sort="Wodchis, Walter P" uniqKey="Wodchis W" first="Walter P." last="Wodchis">Walter P. Wodchis</name><name sortKey="Wodchis, Walter P" sort="Wodchis, Walter P" uniqKey="Wodchis W" first="Walter P." last="Wodchis">Walter P. Wodchis</name></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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