Chen, Ping-Jen; (2022) The longitudinal impact of home healthcare on subsequent healthcare outcomes in people with dementia. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Home healthcare (HHC) comprises clinical services provided by medical professionals for people with various levels of care needs and health conditions. HHC may reduce care transitions, but its longitudinal effect on subsequent healthcare outcomes in people with dementia (PWD) towards the end of life remains unclear. / Methods: This PhD consists of both a systematic review which synthesises the literature on HHC’s effect on end-of-life outcomes in PWD (Chapter 3) and a series of quantitative analyses based on the Taiwan national database. I investigated the temporal trend and determinants of the medical care needs of people receiving HHC (Chapter 5), a nested case-control analysis to explore the association between HHC and burdensome end-of-life transitions in PWD (Chapter 6), and a nested case-control and matched cohort studies to identify determinants of receiving HHC and subsequent outcomes – including hospitalisation, palliative care, and mortality – in four steps (Chapter 7). Finally, I examined the longitudinal association between HHC and the aforementioned outcomes (Chapter 8). / Results: The systematic review shows the dearth of dementia-specific research regarding the impact of HHC on end-of-life outcomes. The importance of advance care planning, training and external support of palliative care, and coordination between health and social care are highlighted. In the quantitative studies, I found that females, low income, rural areas and dementia are associated with high medical care needs among HHC recipients. In the nested case-control analysis, HHC had inverse effects on end-of-life burdensome transitions in different periods of the end of life (a higher risk in the last 90 days of life but a lower risk in the last 3 days of life). In the longitudinal survival analysis, one-third of the study cohort died in the first year of follow-up. HHC was associated with an increased risk of subsequent hospitalisation during the follow-up period. HHC was associated with decreased subsequent palliative care use during 180 days of follow-up and had no difference in the subsequent probability compared to those without HHC. Concerning mortality, HHC was associated with a consistently higher risk of death in PWD with no enteral, urinary and tracheal tube use at baseline. For PWD with any interventional tube use, HHC was associated with a lower risk of death during the first year of follow-up. However, the protective effect of HHC on death decreased to no difference compared to the group without HHC after one year of follow-up, and the mortality risk of the exposure group increased after 3 years of follow-up. / Conclusion: In PWD enrolled in HHC, I recognised the unmet needs for management which aim for acute illness/ decline during HHC. The short median survival and its wide range in PWD receiving HHC highlight the importance of advance care planning and anticipatory end-of-life care support, alongside routine services for physical care and maintenance of function. The odds of receiving subsequent palliative care do not increase when the mortality risk increases. Both an early palliative care approach by primary HHC clinicians and timely referral to specialist palliative care support may be crucial. More knowledge regarding the cost-effectiveness research of integration between health and social care is vital for both academic and clinical practice. I have initiated a nationwide cohort study (HOLISTIC) in Taiwan to address more comprehensive issues in HHC (Chapter 10).

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