Variation in healthcare services utilization and continuity of care in long-term care facilities: a cross-sectional study

Abstract

Background: Primary and specialist healthcare services are critical to ensuring high-quality care for people living in long-term residential aged care facilities (LTCFs). In Australia, these government-subsidized services include general practitioner attendances, health assessments, management plans, allied health services, pain medicine specialists, and mental healthcare, among others. Although the utilization of these services is known to be suboptimal, the extent and nature of variation in their use across LTCFs nationally remain unknown. Importantly, variation that is not attributable to resident needs or planned system design-termed unwarranted variation-has been shown to negatively impact health outcomes and warrants investigation. To address this gap, this population-based study aims to examine the national variation in primary and selected specialist healthcare services utilization and continuity of care in residential aged care facilities and characteristics of facility utilization outliers.

Methods: A national cross-sectional study of 173,275 non-Indigenous residents aged ≥65 years from 2,744 Australian facilities in 2019 was conducted. To evaluate continuity of care, the cohort was restricted to LTCF residents who entered care in 2019 and were alive for at least six months (N = 41,654 individuals in 2,680 LTCFs). Adjusted median service and continuity of care utilization per 100 residents were calculated. National variation in the rate of healthcare service utilization was quantified using inlier-ranges, categorized as minimal = 0, low < 20, moderate = 20-79, high = 80-99, and maximal = 100.

Results: Maximal variation for services with moderate utilization (median = 22.1-60.6/100 residents) was observed for after-hours attendances, urgent after-hours attendances, health assessments, management plans, podiatry, and optometric services. Continuity of care had low-to-moderate utilization (median = 13.4-26.6/100) and moderate-to-high variation (inlier-range = 68-95.5). Some services had high (median = 99.9/100, general attendances) or low (median < 8.2/100, specialist attendances) utilization and low-to-moderate variation. A small number of mostly high-utilization outliers were identified.

Conclusions: There is substantial variation in utilization of healthcare services and continuity of care amongst residential aged care facilities nationally. While some facilities deliver high levels of preventive and disease management healthcare services supporting residents to have high continuity of care, many facilities face challenges facilitating access to adequate healthcare for their residents.

Keywords: Continuity of patient care; General practice; Health services for the aged; Long-term care; Primary healthcare.

Fig. 1

Adjusted utilization of health assessments per 100 residents of long-term care facilities by facility characteristics. Note. N = 2733. On an individual level, utilization of a service was measured as a binary variable with at least one utilization versus none. The adjusted utilization per 100 residents can thus be understood similar to a percentage of residents who received the service, adjusted by resident-mix in terms of age, sex, and comorbidities. Each data point represents one long term care facility. The shape of a point represents service home remoteness (dots = metropolitan, triangles = non-metropolitan). The size of a data point represents the long-term care facility size. The color represents the ownership type. Data points classified as outliers are represented with grey dots mirroring their utilization level above or below the whiskers

Fig. 2

Adjusted prevalence of continuity of care per 100 residents by long-term care facility characteristics. Note. N = 2680. On an individual level, prevalence of continuity of care– usual GP was measured as a binary variable such that care continued after entry into long term care with the most frequently seen GP before entry, or not. The adjusted utilization per 100 residents can thus be understood similar to a percentage of residents who experienced continuity of care, adjusted by resident-mix in terms of age, sex, and comorbidities. Each data point represents one long-term care facility. The shape of a point represents long term care facility remoteness (dots = metropolitan, triangles = non-metropolitan). The size of a data point represents the long-term care facility size. The color represents the ownership type. Data points classified as outliers are represented with grey dots mirroring their utilization level above or below the whiskers

Fig. 3

Adjusted utilization of nurse practitioners per 100 residents of long-term care facilities by facility characteristics. Note. N=2733. On an individual level, utilization of a service was measured as a binary variable with at least one utilization versus none. The adjusted utilization per 100 residents can thus be understood similar to a percentage of residents who received the service, adjusted by resident-mix in terms of age, sex, and comorbidities. Each data point represents one long term care facility. The shape of a point represents long term care facility remoteness (dots=metropolitan, triangles=non-metropolitan). The size of a data point represents the long-term care facility size. The color represents the ownership type. Data points classified as outliers are represented with grey dots mirroring their utilization level above or below the whiskers