Determinants of access of frail, community‐residing older adults to geriatricians in Ontario

Abstract

ObjectivesLittle is known about determinants of access to community‐based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.MethodsThis was a population‐based, retrospective cohort study of frail community‐dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012–2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post‐HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.ResultsOnly 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c‐statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision‐making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c‐statistic = 0.77).ConclusionsFew frail, community‐dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re‐examine the referral process for geriatricians and the allocation of limited specialized resources.

Not enough geriatricians or not where they are needed?

“…In this issue of JAGS, Hogeveen et al report the results of a population-based retrospective cohort study that addresses these questions. 10 The study objectives were to "investigate whether the competencies of geriatric medicine, articulated as the domains of the Geriatric 5Ms framework, were predictive of outpatient receipt of geriatric medicine evaluation among community-residing home care clients"; and to explore other determinants of access to care from a geriatrician in an expanded model.…”

“…The primary analysis tested the association between the derived 5Ms score and geriatrician contact by HC patients within the 90 days following their admission assessment. A secondary analysis examined the association between an expanded definition of need, that is, the 5 M score plus specific medical conditions, 10 and geriatrician contact by HC patients.…”