The Raval Nord Study: Descriptive Analysis of Survival Rates During
Transcripción
The Raval Nord Study: Descriptive Analysis of Survival Rates During
The Raval Nord Study: Descriptive Analysis of Survival Rates During 10 Years of Home Care Josep Maria Segura Noguera Núria Bastida Bastús Núria Martí Guadaño Montserrat Riba Romeva Mireia Marsà Carretero Santiago Lancho Lancho A large part of this population presents chronic, incapacitating illnesses that have led to a growing homebased social and health care effort (Freer, 1990; Luker & Perkins, 1987; Taylor, 1978), which involves allocating more human and material resources to meet the growing home care demand. Although the help of other support professionals may be needed on certain occasions, home care is provided almost entirely by the primary care team (PCT; López Pisa, Maymó, & Giró, 1989; Torra, 1989). A biopsychosocial circumstance, such as the patient’s inability to leave his or her home as a result of his or her illness, becomes the raison d’être of this care. Various studies have shown an increase in the dependent elderly population secondary to progressive aging. According to the 1992 Enquesta de Salut de Barcelona (Barcelona Health Care Survey; Barcelona City Council, Public Health Department, 1992-1993), 20% of patients older than 65 presented some form of limitation affecting their day-to-day life. This figure seems to be growing and reached more than 30% in the 2000 Survey (Barcelona City Council, Public Health Department, 2000). This population is unable to leave the home without assistance. Home visits to these housebound patients serve as a support to caregivers This longitudinal study describes the urban population of chronic patients treated at home and analyzes survival rates of the first 10 years (1992 to 2002) of a primary health care team. Participants included all of the 1,357 home care chronically ill patients registered since the beginning of a home care program (May 1994 to December 2002). The average age was 82 years, 68% were female, 76% lacked elevators, 18% cited loneliness, 11% were totally dependent, and 20% suffered severe cognitive alterations. Cox’s proportional risk method and survival probability curves by the Kaplan-Meier method were used. Factors linked to lower survival (p < .001) included being male (relative risk, RR = 1.67), existence of terminally ill patients because of neoplastic pathologies (RR = 7.72), living accompanied by other people (RR = 2.39), deteriorated cognitive function status (slight moderate, RR = 1.74; severe, RR = 2.71), and worsening degree of autonomy (partially dependent, RR = 1.63; totally dependent, RR = 3.54). I ncreases in life expectancy in recent years have led to a progressive aging of the population (Gillick, 1989; Spanish Ministry of Social Affairs, 1991). Key Words: home; care; health; service; primary; survival Authors’ Note: The authors appreciate the work done by all the members of the Raval Nord primary care team in implementing the Atencion Domiciliaria program, which has made it possible to draw up this article. We would also like to thank the chronic home care patients and their families for their willingness to cooperate at all times. Home Health Care Management & Practice / February 2007 / Volume 19, Number 2, 118-125 DOI: 10.1177/1084822306294479 ©2007 Sage Publications 118 Segura Noguera et al. / Home Care Survival Rates 119 FIGURE 1 Study Schematic 1,357 chronic home care patients treated by the Raval Nord PCT Monitoring over 104 months Complete monitoring 952 (70.2%) Incomplete monitoring 405 (29.8%) No significant differences Survival, continues in program Survival, discharged from program No survival due to death Discharge from program due to change of address Discharge from program due to institutionalization Discharge from program due to other causes Note: PCT = primary care team. and help the family in the decision as to when hospitalization is appropriate. The home care program called the Atencion Domiciliaria (ATDOM) is the necessary instrument for the PCT to provide proper, organized home care (Borrell, 1986; López Pisa & Maymó Pijuan, 1991). To this end, advance planning taking into account the available resources is required (Pinault & Daveuly, 1989; Segura, Bastida, Martí, & González, 1994; Segura et al., 1996), and it is necessary to make regular assessments to ensure attainment of previously defined objectives. One of the primary goals of this program, whose coverage has ranged from 5% to 8% of the elderly population, was to determine if greater physical and mental deterioration could be linked to lower survival. It was decided to analyze these aspects of home care. The objective of the present study is to analyze survival rates among this population of housebound patients who have received home care during the first 10 years (1992-2002) of operation of a PCT. Figure 1 provides the reader with a visual of the flow of this study. MATERIAL AND METHOD The Dr. Lluís Sayé Primary Care Centre, located in the Ciutat Vella district of Barcelona, opened its doors on December 14, 1992. The PCT now has 11 basic health care units (BHUs) for general medicine. Each BHU, which comprises a doctor and a nursing graduate, provides care 4 days a week at the center and spends the other day of the week performing home care, both spontaneous and scheduled, through an ATDOM program set up in May 1994. In addition, the nursing staff spends another weekday working in this activity on a part-time basis. The Raval Nord borough, with a population of 17,501 inhabitants according to the 2000 census, has 4,446 people aged 65 or older (25.4% of the total). The area is characterized by an important shortage of lifts (76%) in buildings. During the past 10 years, the ATDOM program has included all chronic home care patients requiring care at home because of mobility problems that prevented them from going to the primary care center. Thus, one criterion of a housebound patient is the inability to be transported to the PCT as a result of his or her illness. The maximum monitoring period was 104 months, from May 1994 to December 2002. The request for home care was made in most cases by the patient’s family (61%) or by the PCT itself (26%), whereas social services advised it in half of the remaining 13% of cases. On some occasions, the aid of the Home Care Support Team (PADES), including a doctor, nursing staff, and social worker, has been required, particularly to care for patients classified as terminal in the target inclusion group. 120 HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2007 The data recorded in the “control and evaluation record” have been used to analyze several variables referring to the patients’ characteristics. These characteristics included • • • • • • • • • • Age Gender Civil status Origin of the demand Target inclusion group or category in the program Prevailing pathology Degree of autonomy Mental condition Loneliness–company Time included in the program When the patient was discharged from the program, the cause for the discharge was analyzed. The following were reasons for discharge: • Improvement enabling the patient to visit the Public Health Centre (PHC) by his or her own means • Death • Change of address • Admission to nursing homes outside the borough • Other causes Physical capacity was assessed using the Katz index (Alvarez et al., 1992; Katz, Downs, Cash, & Grotz, 1970; Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963), a scale that uses six basic activities of daily living (ADLs; bathing, dressing, toileting, transferring, continence, and feeding) to classify the degree of autonomy, ranging from independent for all functions (A) to dependent for all functions (G). The H category on the Katz index includes cases that are not classifiable according to the remaining categories and in practice behaves like a category with slight dependence. Mental capacity was assessed using Pfeiffer’s Short Portable Mental Status Questionnaire. This is a very useful test given its speed of application, combined with acceptable sensitivity and specificity (González & Salgado, 1992; González Montalvo, Rodríguez Mañas, & Ruipérez Cantera, 1992; Kane & Kane, 1993; Vinyoles, Recasens, Salvador, & Sáez, 1992), and it serves to classify patients according to their cognitive status. These classifications are • • • • Intact Slight deterioration Moderate deterioration Severe deterioration However, the test is impossible to administer to some patients with severe deterioration. The data were entered into a database (DbaseIII Plus) and then processed using the SPSS10.0 for Windows package both for descriptive statistics and to analyze survival. For the latter case, the values of the most complex variables, such as cognitive status and Katz index, were grouped together. Also grouped together were some of the initial categories of the target group variables (chronic pathology, transitory home care, dementias, terminal patients, and home care risk groups) and loneliness–company (lives alone, lives with other people older or younger than 60). For the target group, cases of home care risk were also categorized as a chronic pathology. For loneliness–company, people who live with others were classified under a single category. For cognitive status, slight and moderate deterioration were merged, and cases where the test could not be administered were included in the severe category. For the Katz index, the categories were simplified to independent (Katz index A), partially dependent (Katz indexes B, C, D, E, F, H), and totally dependent (Katz index G). Cox’s proportional risk method was used to determine the estimated relative risk (RR) of mortality depending on the different recoded categories of the studied variables, whereas the relevant combined survival probability curves were calculated according to the Kaplan-Meier method. The statistical significance level used at all times was α = .05. Finally, an adjusted analysis with all variables associated with survival was performed to assess whether all preserved their significance. RESULTS A total of 1,357 chronic patients received home care through the ATDOM program. Notably, 18% of the patients lived in nursing homes in the borough, whereas another 18% lived alone. Although the remaining 64% lived in dwellings with others, 33% of them lived with people older than 60. There is a clear prevalence of females (68.3%) beyond age 75 (p < .001), as shown in Table 1. As for civil status, widowed topped the list with 50.7%, followed by married (32.1%), single (14.8%), and other (2.4%), with significant differences according to gender (p < .001). There were more men among the married (61.0%) and more women among the single (69.4%). In the widowed category, there was a significant prevalence of women (87.1%). The average Segura Noguera et al. / Home Care Survival Rates TABLE 1 Chronic Home Care Patients According to Age and Gender Male Age Group Younger than 35 35-64 65-74 75-84 85 or older Overall Female n % n % 6 57 102 146 119 430 54.6 69.5 53.4 29.2 20.7 31.7 5 25 89 353 455 927 45.4 30.5 46.6 70.8 79.3 68.3 121 Figures 2 to 6 show the combined Kaplan-Meier survival probability curve according to the mentioned predictive factors. Significant differences (p < .001) were also found in average age depending on the survival of the patients (yes = 73, no = 79). Patients without a full follow-up (29.8%) did not present significant differences in the studied variables. The analysis adjusted by variables associated with survival did not experience changes of interest with respect to the raw analysis (all variables maintained their significance, except cognitive status). Discussion age was 82 (SD = 11), with differences (p < .001) depending on gender (female = 84, male = 77). The distribution according to target groups for inclusion in the program included chronic pathology (78.4%), terminally ill (7.9%), dementias (6.3%), transitory home care (5.7%), and belonging to risk group (1.7%). As for the 1,091 (80.4%) program discharges, 194 (14.3%) patients were admitted to nursing homes and social health care centers outside our area, 130 (9.6%) moved away from the borough, 116 (8.5%) recovered their former autonomy, and 570 (42.0%) died. In the 81 remaining cases (6.0%), contact with the patient was lost, and therefore the reason for leaving the program was unknown. Of the patients, 10.9% were dependent for all basic ADLs (Katz index G), whereas 58.9% were partially dependent (Katz index B 22.6%, C 13.1%, D 6.6%, E 4.1%, F 7.8%, H 4.7%), and 30.2% were independent with regard to all activities (Katz index A). Of the patients, 54.1% did not present alterations in the mental status test used, whereas 16.4% showed slight deterioration, 9.7% showed modest deterioration, and 19.8% presented severe deterioration (in 4.1% of cases, the test was virtually impossible to administer). As expected, the better degree of autonomy and cognitive status of patients living alone was significant (p < .001). The factors that showed a significant link (p < .001) to lower survival were male gender (RR = 1.67), the need to be accompanied (RR = 2.39), deteriorated cognitive status (slight-moderate RR = 1.74, severe RR = 2.71), and a lower degree of autonomy (partially dependent RR = 1.63, totally dependent RR = 3.54) and the terminal patient target group (mostly because of neoplastic pathology; RR = 7.72). Table 2 shows Cox’s proportional risk analysis for the different variable values studied. The growing importance of home care as part of primary health care is a phenomenon that will, in the future, condition the allocation of increasing human and material resources. The ATDOM program has proved to be an efficient tool (Contel & González, 1995; Espinosa & Muñoz, 1995; Lindoso, Valencia, Fernández, Álvarez, & Álvarez, 1994; López Pisa & Agüera Villar, 1995) that facilitates patient monitoring. It is important to mention that the implementation of our program is appropriate even though the patients were independent for all daily living activities at home because home visit criteria were that they could not leave their home to go visit the PHC as a result of their illnesses. The specific medical cause for the patient being housebound had little effect on the process of home visiting. The basic profile of patients included in the ATDOM program reveals a strong prevalence of widows, which is consistent with the majority of studies conducted (Bilbao et al., 1994; Hernando et al., 1992; Monte, Alonso, Cabal, & Iglesias, 1995; Sanz, Morente, Calvo, Gallego, & Carra, 1995) because of the greater life expectancy of women. The percentage of patients with a good degree of autonomy is lower than in studies that analyze the degree of autonomy in the overall elderly population (Alvarez et al., 1992; Benítez, Hernández, & Barreto, 1994; Monte et al., 1995). However, if we compare these data with those of another study (Hernando et al., 1992) that analyzes this aspect exclusively among the chronic home care patient population, the figure is higher because in many cases the patients’ inability to go to the PHC by their own means was because of the absence of lifts and the pluripathology they presented. We measured their degree of autonomy according to the Katz index because its usefulness has been demonstrated in various studies (Alvarez et al., 122 HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2007 TABLE 2 Estimated Relative Risks of Mortality of Chronic Home Care Patients According to Studied Variables Variable Relative Risk Gender Female (reference category) Male Target group Chronic pathology (reference category) Transitory home care Dementias Terminal patient Loneliness–company Lives alone (reference category) Lives with others Cognitive status Intact (reference category) Slight to moderate deterioration Severe deterioration Katz index Independent (reference category) Partially dependent Totally dependent 95% Confidence Interval p 1.67 1.41-1.97 < .001 0.16 1.08 7.72 0.09-0.29 0.80-1.47 6.12-9.74 < .001 .602 < .001 2.39 1.80-3.18 < .001 1.74 2.71 1.13-2.69 1.75-4.19 .012 < .001 1.63 3.54 1.29-2.05 2.63-4.76 < .001 < .001 FIGURE 2 Survival Curve According to Gender FIGURE 3 Survival Curve According to Loneliness–Company 1.2 1.2 1.0 1.0 .8 .8 .6 1 .6 1 .4 .4 2 .2 0.0 −20 2 0 20 40 60 .2 80 Monitoring time in months 100 120 0.0 −20 0 20 40 60 80 100 Monitoring time in months Gender 1: female Loneliness−Company 2: male 1: lives alone 2: lives with others 120 Segura Noguera et al. / Home Care Survival Rates FIGURE 4 Survival Curve According to Target Group 123 FIGURE 5 Survival Curve According to Cognitive Status 1.2 1.0 .8 1 .6 .4 .2 2 3 0.0 0 20 40 60 80 Monitoring time in months 100 120 Mental Test 1: intact 1992; Cruz Jentoft, 1991; González & Salgado, 1992). The usefulness of this index is confirmed even further by a previous study that we conducted (Segura, Bastida, Martí, & Riba, 1997), in which it proved to be a good predictor both of the patients’ survival and of visit frequency rates. It is important to note that our results on survival are consistent with other studies (González Montalvo, Jaramillo Gómez, Rodríguez Mañas, Guillén Llera, & Salgado Alba, 1990; Palomo & Gérvas, 2000) in terms of lower survival rates among males. This last study (Palomo & Gérvas, 2000) also pointed out, like ours, the importance of assessing the degree of autonomy and of the doctor’s initial opinion in relation to possible survival, a variable that we did not study. Some anecdotal facts gleaned from our study have an explanation. Thus, the greater survival rate of patients who live alone is explained by its association with a greater degree of autonomy and better cognitive status. Patients who we could not assess using the Short Portable Mental Status Questionnaire (because of their being very highly evolved dementias) were considered to be equivalent to severe dementia. The different, foreseeable evolution in mortality of the different target inclusion groups was 2: slight-moderate det. 3: severe det. clear. Although these differences are because of the characteristics of the patients included in the program, we believe it is important to describe them. Finally, it is also important to note that most of the factors associated with the survival of these patients were already evidenced in the analysis conducted 2 years after the start of monitoring (Segura et al., 1997), although the existing differences according to the Katz index have lessened slightly over time. The incomplete monitoring of 29% of the patients because of changes of address, admission to nursing homes outside our area, and other unknown causes does not represent a limitation with regard to the results because the analysis of these patients did not differ in terms of predictive survival variables. We must make it clear that the work done in home care in the Raval Nord borough during these 10 years was done prior to the start of the Salut a Casa (“Health at Home”; Catalan Health Institute, 2001) program recently implemented in the city of Barcelona and therefore also integrates the Raval Nord ATDOM program. This made it necessary to adapt our program to the objectives, indicators, and assessment scales agreed to for the entire city. Finally, we believe it is important to note that although there are few primary care studies that analyze patient 124 HOME HEALTH CARE MANAGEMENT & PRACTICE / February 2007 FIGURE 6 Survival Curve According to Degree of Autonomy Barcelona City Council, Public Health Department. (2000). Enquesta de salut de Barcelona 2000 [Barcelona’s health questionnaire 2000]. Barcelona, Spain: Author. 1.2 1.0 Benítez, M. A., Hernández, P., & Barreto, J. (1994). Evaluación geriátrica exhaustiva en atención primaria: valoración de su utilidad [Exhaustive evaluation of geriatric services in primary care: An assessment of their usefulness]. Atención Primaria, 13(1), 20-26. .8 .6 Bilbao, I., Gastaminza, A. M., García, J. A., Quindimil, J. A., López, J. L., & Huidobro, L. (1994). Los pacientes domiciliarios crónicos y su entorno en atención primaria de salud [Chronic patients at home and their primary health environment]. Atención Primaria, 13(4), 188-190. 1 .4 Borrell, F. (1986). Programas de salud en atención primaria. Necesidad de innovaciones metodológicas [Health programs in primary care. Need of methodological innovations]. Atención Primaria, 3(2), 91-96. 2 .2 0.0 −20 Barcelona City Council, Public Health Department. (1992-1993). Enquesta de salut de Barcelona 1992-1993 [Barcelona’s health questionnaire 1992-1993]. Barcelona, Spain: Author. Catalan Health Institute. (2001). “Salut a casa” program. Implementació de l’atenció domiciliària a Barcelona [“Salut a Casa” program. Implementation of the home care in Barcelona]. Barcelona, Spain: Author. 3 0 20 40 60 80 100 120 Monitoring time in months Katz Index 1: independent 2: partially dependent 3: totally dependent Contel, J. C., & González, M. (1995). Reflexión sobre la implementación de programas de atención domiciliaria [Reflection about the implementation of the home care programs]. Enfermería Clínica, 5(5), 205-211. Cruz Jentoft, A. J. (1991). El índice de Katz [The Katz Index]. Revista Española de Geriatría y Gerontología, 26, 338-348. Espinosa, J. M., & Muñoz, F. (1995). Evaluación de los programas de atención domiciliaria en atención primaria de salud [An evaluation of primary home health care programs]. Cuadernos de Gestión, 1(1), 24-32. Freer, C. B. (1990). Screening the elderly. British Medical Journal, 300, 1.447-1.448. survival, the ATDOM program does provide proper recording means for studying this aspect. Thus, an appropriate integral assessment of home care makes it possible to detect problems requiring new objectives to be defined. The following key points highlight the findings of this study: • Increased life expectancy has led to a progressive aging of the population and growing home-based social and health care. • The housebound population is characterized by being of a very advanced age, with high mortality, requiring continued home care. • Predictive variables of patient survival include gender, the target inclusion group, loneliness–company, cognitive function, and degree of autonomy. REFERENCES Alvarez, M., Alaiz, A., Brun, E., Cabañeros, J., Calzón, M., Cosío, I., et al. (1992). Capacidad funcional de pacientes mayores de 65 años, según el índice de Katz. Fiabilidad del método [The functional capacity of patients over 65 according to the Katz Index. How reliable is this method?]. Atención Primaria, 10, 812-816. Gillick, M. R. (1989). Long-term care options for the frail elderly. Journal of American Geriatric Society, 37, 1198-1203. González, J. I., & Salgado, A. (1992). 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