Primary care contacts, continuity, identification of palliative care needs, and hospital use: a population-based cohort study in people dying with dementia

Abstract

Background: Reducing hospital admissions among people dying with dementia is a policy priority. Aim: To explore associations between primary care contacts, continuity of primary care and identification of palliative care needs with unplanned hospital admissions among people dying with dementia. Design & setting: Retrospective cohort study using the Clinical Practice Research Datalink linked with hospital records and Office for National Statistics data. Adults (>18 years) who died between 2009-2018 with a diagnosis of dementia. Methods: We evaluated associations between GP contacts, the Herfindahl Hirschman continuity of care (CoC) score and palliative care needs identification before the last 90 days of life with multiple unplanned hospital admissions in the last 90 days using random-effects Poisson regression. Results: We identified 33714 decedents with dementia: 64.1% female, mean age 86.6 (SD 8.1), mean comorbidities 2.2 (SD 1.6). 1894 (5.6%) had multiple hospital admissions in the last 90 days of life (increase from 4.9% (95% CI 4.2-5.6) in 2009 to 7.1% (95% CI 5.7-8.4) in 2018). Participants with more GP contacts had higher risk of multiple hospital admissions (IRR 1.08, 95% CI 1.05-1.11). Higher CoC scores (IRR 0.79, 95% CI 0.68-0.92) and identification of palliative care needs (IRR 0.66, 95% CI 0.56-0.78) were associated with lower frequency of these admissions. Conclusions: Multiple hospital admissions among people dying with dementia are increasing. Higher CoC and identification of palliative care needs are associated with a lower risk of multiple hospital admissions in this population, and might help prevent these admissions at the end of life.

Inclusion of palliative and end of life care in health strategies aimed at integrated care: a documentary analysis

“…Integrated models of care that help to ensure patients’ needs are met and care is delivered in the most appropriate setting 26 , may also reduce the need for emergency care. This is a particularly important consideration since Emergency Department visits for people approaching the end of life are increasing 27 .…”

Inclusion of palliative and end of life care in health strategies aimed at integrated care: a documentary analysis

“…Integrated models of care that help to ensure patients' needs are met and care is delivered in the most appropriate setting 24 , may also reduce the need for emergency care. This is a particularly important consideration since Emergency Department visits for people approaching the end of life are increasing 25 .…”

Living well with dementia

“…‘Dying well’ is also critical to ‘living well’. Many people with dementia become socially isolated, increasingly frail with repeated hospital admissions when they are dying from their dementia (Leniz et al., 2022). Good continuity of primary care has been shown to reduce these admissions towards the end of life (Leniz et al., 2022) and reduce recognised adverse health outcomes (Delgado et al., 2022).…”

“…There is increasing evidence that continuity of care improves outcomes for PLWD. Studies have found that continuity of primary care results in lower rates of delirium and incontinence (Delgado et al., 2022) and better identification of palliative needs and fewer unscheduled hospital admissions (Leniz et al., 2022). Although recent primary care policy has perhaps prioritised access over continuity, for this vulnerable group with high healthcare need, consider promoting continuity of care and taking professional responsibility for these patients.…”