Diverse perspectives on hospitalisation events among people with dementia: protocol for a multisite qualitative study

IntroductionPeople living with dementia (PLWD) are more likely to experience hospitalisation events (hospitalisation, rehospitalisation) than those without dementia. Many hospitalisation events, particularly rehospitalisation within 30 days of discharge, are thought to be avoidable. Yet our understanding of dementia-specific risk and protective factors surrounding avoidable hospitalisation is limited to specific intersetting transitions and predominantly clinician perspectives. Broader insights are needed to design accessible and effective solutions for reducing avoidable hospitalisations. We have designed the Stakeholders Understanding of Prevention Protection and Opportunities to Reduce HospiTalizations (SUPPORT) Study to address these gaps. The objectives of the SUPPORT Study are to elicit and examine family caregiver, community and hospital providers’ perspectives on avoidable hospitalisation events among PLWD, and to identify opportunities for effective prevention.Methods and analysisWe will conduct a multisite, descriptive qualitative study to interview around 100 family caregivers, community and hospital providers. We will identify and sample from regions and communities with higher socio-contextual disadvantage and hospital utilisation, and will aim to recruit individuals representing diverse racial/ethnic backgrounds. Interviews will follow a descriptive qualitative design in conjunction with constant comparison techniques to sample divergent situations and events. We will employ a range of analytical approaches to address specific research questions including thematic (inductive and deductive), comparative and dimensional analysis. Interviews will be conducted individually or in focus groups and follow a semistructured interview guide.Ethics and disseminationThe study is approved by the University of Wisconsin-Madison Institutional Review Board. Informed consent procedures will incorporate steps to evaluate capacity to provide informed consent in the event that participants express concerns with thinking or memory or demonstrate challenges recalling study details during the consent process to ensure capacity to consent to participation. A series of publicly available reports, seminars and symposia will be undertaken in collaboration with collaborating organisation partners.

Inequalities in avoidable hospitalisation in large urban areas: retrospective observational study in the metropolitan area of Milan

ObjectiveSignificant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence.DesignRetrospective observational study.SettingPublic and accredited private hospitals in the metropolitan area of Milan. Data obtained from the hospital discharge database of the Italian Health Ministry.Participants472 579 patients hospitalised for ambulatory care sensitive conditions and resident in the metropolitan area of Milan from 2005 to 2016.Outcome measureAge-adjusted rates of avoidable hospitalisations; OR for hospital admissions with ambulatory care sensitive conditions.MethodsAge-adjusted rates of avoidable hospitalisations in the metropolitan area of Milan were estimated from 2005 to 2016 using direct standardisation. For the hospitalised population, multilevel logistic regression model with patient random effects was used to identify patients, hospitals and municipalities’ characteristics associated with risk of avoidable hospitalisation in the period 2012–2016.ResultsThe rate of avoidable hospitalisation in Milan fell steadily between 2005 and 2016 from 16.6 to 10.5 per 1000. Among the hospitalised population, the odds of being hospitalised with an ambulatory care sensitive condition was higher for male (OR 1.42, 95% CI 1.36 to 1.48), older (OR 1.012, 95% CI 1.01 to 1.014), low-educated (elementary school vs degree OR 4.23, 95% CI 3.72 to 4.81) and single (vs married OR 2.08, 95% CI 2.01 to 2.16) patients with comorbidities (OR 1.47, 95% CI 1.38 to 1.56); avoidable admissions were more frequent in public non-teaching hospitals while municipality’s characteristics did not appear to be correlated with hospitalisation for ambulatory care sensitive conditions.ConclusionsThe health system in metropolitan Milan has experienced a reduction in avoidable hospitalisations between 2005 and 2016, quite homogeneously across its 134 municipalities. The study design allowed to explore inequalities among the hospitalised population for which we found specific sociodemographic disadvantages.

Health professional and patient perspectives of factors associated with potentially avoidable hospitalisations in a rural Australian setting: a qualitative study

Background Potentially avoidable hospitalisations are a proxy measure of effective primary care at a population level. Hospitalisations for the chronic health conditions of diabetes, congestive cardiac failure and chronic obstructive pulmonary disease account for half of the potentially avoidable hospitalisations for chronic diseases. These hospitalisations are higher in rural areas and socioeconomically disadvantaged areas. Scarce qualitative research has focussed on the identification of factors associated with potentially avoidable hospitalisation from the perspectives of health professionals or patients. This study sought to identify factors associated with potentially avoidable hospitalisations in a rural context from the perspectives of patients and health professionals. Methods Patients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia, and health professionals involved in the care of patients with these conditions, were invited to participate in interviews between September and October 2019. Conversations were recorded, transcribed verbatim and analysed using thematic analysis. Results Nine patients and 16 health professionals participated in semi-structured interviews. Five themes were identified (representing factors associated with potentially avoidable hospitalisation); namely General Practitioner involvement, individual patient factors, the influence of the rural locality, medication awareness and health service access. Within these themes, inter-related subthemes emerged including sub-optimal disease management plans, barriers to accessing general practice, poor mental health, patients living alone, healthcare costs, sub-optimal communication and poor connectivity between patients and beneficial services. Conclusion Factors associated with potentially avoidable hospitalisation in this rural area were complex and inter-related. These factors encompassed health service access and disease management, as well as socioeconomic disadvantage. Results suggest that improved indicators of access to effective health services, including primary care, are necessary to address potentially avoidable hospitalisation.