Context Dementia is associated with increased rates and often poorer outcomes of hospitalization, including worsening cognitive status. New evidence is needed to determine whether excess admissions in dementia might be potentially preventable. Objective To determine whether dementia onset is associated with higher rates or different reasons for hospitalization, particularly for ambulatory care sensitive conditions (ACSCs) for which proactive outpatient care might prevent the need for a hospital stay. Design, Setting, and Participants We conducted a retrospective analysis of hospitalizations among 3019 participants in Adult Changes in Thought (ACT), a longitudinal cohort study of initially non-demented adults aged 65 and older enrolled in an integrated healthcare system. Automated data were used to identify all hospitalizations from time of enrollment in ACT until death, disenrollment from the health plan, or end of follow-up, whichever came first. The study period spanned from February 1, 1994 to December 31, 2007. Main Outcome Measures Hospital admission rates for dementia and dementia-free groups, for all causes, by type of admission, and for ACSCs. Results Four hundred ninety-four cognitively normal individuals eventually developed dementia and 427 (86%) of these persons were admitted at least once; 2525 remained dementia free and 1478 (59%) were admitted at least once. The unadjusted all-cause admission rate in the dementia group was 419 admits per 1000 person-years vs. 200 admits/1000 in the dementia-free group. After adjustment for age, gender, and other potential confounders, the ratio of admission rates for all-cause admissions was 1.41 (95% confidence interval [CI], 1.23 to 1.61; P<.0001), while for ACSCs, the adjusted ratio of admission rates was 1.78 (95% CI, 1.38 to 2.31; P<.0001). Adjusted admission rates classified by body system were significantly higher in the demented group for most categories. Adjusted admission rates for all types of ACSCs, including bacterial pneumonia, congestive heart failure, dehydration, duodenal ulcer, and urinary tract infection, were significantly higher among those with dementia. Conclusions Among patients aged 65 years and older, incident dementia was significantly associated with increased risk of hospitalization, including hospitalization for ACSCs.

OBJECTIVE -To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients.RESEARCH DESIGN AND METHODS -We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients Ն30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of ϳ8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA 1c levels and health care use and cost data was collected from HMO administrative systems.RESULTS -In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA 1c levels.CONCLUSIONS -Periodic primary care sessions organized to meet the complex needs of diabetic patients improved the process of diabetes care and were associated with better outcomes. Diabetes Care 25:695-700, 2001

Use of smoking-cessation services varies according to the extent of coverage, with the highest rates of use among smokers with full coverage. Although the rate of smoking cessation among the benefit users with full coverage was lower than the rates among users with plans requiring copayments, the effect on the overall prevalence of smoking was greater with full coverage than with the cost-sharing plans.