Ageing

Containing hospital costs by limiting bed availability and reducing length of stay may no longer be a viable strategy

Natasha Reid · Thakeru Gamage · Stephen J Duckett · Leonard C Gray

To the Editor: Nursing homes need enough qualified, skilled staff to care for residents with diverse clinical needs and preferences. Even though most staff are personal care workers, registered nurses and enrolled nurses represent the majority of registered health care professionals. The Royal Commission into Aged Care Quality and Safety heard that, by 2050, best practice nursing home care will require about 7170 more enrolled nurses.1,2 Despite this, the importance of enrolled nurses in the sector is overlooked. Newly legislated minimum time standards and requirements for registered nurses’ presence 24/7 do not explicitly include enrolled nurses.3 This means employers are incentivised to use other staff, particularly personal care workers. There are already reports of providers making enrolled nurses redundant despite staff shortages, risking further workforce deprofessionalisation and possible worse outcomes for both residents and staff.4 Although evidence specific to enrolled nurses is limited and must increase,5 they are valuable, regulated staff members in nursing homes and their role represents an important step in career progression between personal care workers and registered nurses. If Australia is to develop a world‐class aged care sector that prioritises the best possible resident outcomes and experiences and matches staffing levels and skills to the needs of residents, then enrolled nurses must be valued multidisciplinary team members. Necessary legislative change should mandate a minimum time standard for direct care staff that includes clear specification of the enrolled nurses’ role and contribution.

Micah DJ Peters

The case for a market mechanism to improve health system flow and patient care

Benedict Rogers · Juan Paolo Legaspi · Tarun Bastiampillai

The range of prevalence estimates suggests that re-assessing future demand may be appropriate

Annette J Dobson · Leon Flicker · Osvaldo P Almeida · Michael Waller · Kaarin Anstey

Encouraging public compliance with measures that limit community transmission would benefit everyone, with only minor inconvenience

Gwendolyn L Gilbert

Having received three COVID-19 vaccine doses was associated with much lower likelihood of hospitalisation or death

Robert J Ellis · Cameron RM Moffatt · Luke T Aaron · Greta Beaverson · Khin Chaw · Corinne Curtis · Rhett Freeman‐Lamb · Deborah Judd · Khadija Khatry · Yee Sum Li · Terry Nash · Bonnie Macfarlane · Karen Slater · Yudish Soonarane · Mark Stickley · Satyamurthy Anuradha

Australia has effectively instituted a vaccination mandate while maintaining critical workforce capacity in aged care

Sally Hall Dykgraaf · Jane Desborough · Anne Parkinson · Elizabeth A Sturgiss · Paul Kelly · Michael Kidd

Fostering engagement among older patients and families and creating opportunities for decision making about medications are crucial for improved safety and quality across transitions of care

Elizabeth Manias · Carmel Hughes · Robyn E Woodward‐Kron · Christine M Jorm · Guncag Ozavci · Tracey K Bucknall

There is clearly an unmet need for timely, equitable access to cataract surgery in Australia

Alexander Foss

Timely and equitable access to cataract surgery can prevent fall-related injuries and support healthy ageing

Lisa Keay · Kam Chun Ho · Kris Rogers · Peter McCluskey · Andrew JR White · Nigel Morlet · Jonathon Q Ng · Ecosse Lamoureux · Konrad Pesudovs · Fiona J Stapleton · Soufiane Boufous · Jessie Huang‐Lung · Anna Palagyi

Adjusted 30-day and 12-month rates declined for patients who underwent surgery

Lara Harvey · Ian A Harris · Rebecca J Mitchell · Adrian Webster · Ian D Cameron · Louisa Jorm · Hannah Seymour · Pooria Sarrami · Jacqueline Close

To the Editor: Low and colleagues1 highlight the long‐standing issue that the provision of residential aged care in Australia remains grossly inadequate. This is particularly egregious given that these deficits and remedial actions have been known for decades from numerous inquiries commissioned by successive federal governments and reiterated by the Royal Commission. This vacuum is being filled by initiatives undertaken by the Victorian Government in public sector residential aged care services to develop better ways to conceptualise aged care. We acknowledge there is no single ideal model2 for the provision of residential aged care, as there is such wide variation in residential aged care services profiles (eg, number and type of residents, geographic location, physical environment, staffing). However, our recently proposed conceptual model for the provision of residential aged care3 includes many of the necessary aspects recommended by the NHMRC National Institute for Dementia Research Special Interest Group in Rehabilitation and Dementia. Our conceptual model takes as its purpose the provision of person‐centred care to older people with complex health issues, especially those living with dementia. It consists of five domains relevant to the experience of older people living in residential aged care: health care, social inclusion, individual rights, personal care and reablement, and dementia management. The model also supports the dignity of risk and quality of life beyond clinical care to enable older people to thrive. The development of our model involved several stages using a similar approach to model development described in 20104 which comprised: initial conceptualisation and development based on a review of the literature to document and map the key domains of residents’ needs in aged care; brainstorming using the expertise and experience of the research team to refine and categorise the domains and subdomains; extensive consultation with key stakeholders (n = 382) to test the model for feasibility and acceptability (field testing) for the sector; and testing against a range of theoretical organisational failure scenarios (validity checks against coroners’ cases). The model has been presented to the Royal Commission into Aged Care Quality and Safety and published in a peer‐reviewed journal.3 Uptake of this model would allow the Commonwealth government, which finances and regulates this sector, and individual service providers to have a common understanding of aged care. This is an important step towards improving aged care services.

Jo‐Anne Rayner · Deirdre Fetherstonhaugh · Joseph E Ibrahim

Public willingness to pay higher taxes is an important signal, but additional financial pillars are needed

Julie Ratcliffe · Jyoti Khadka · Sheela Kumaran · Billingsley Kaambwa

We urgently need a national strategy to reduce overreliance on hospital services for functional recovery treatments

Ian D Cameron · Maria Crotty · Susan E Kurrle

Estimating expected background rates of hospital transfer and death can inform analyses of vaccine safety

Hazel J Clothier · Yonatan M Mesfin · Steven Strange · Jim P Buttery

The “ABCD of CGA” concept presents varying models of CGA depending on the setting and needs of the patient

Paven Kaur · Jeffrey Rowland · Elizabeth Whiting

Objective: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. Design: Retrospective data linkage study. Setting, participants: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 ‒ June 2014 and were alive six months after entry. Main outcome measures: Inverse probability of treatment‐weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. Results: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4‒1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4‒1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59‒3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18‒2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25‒2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98‒1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. Conclusions: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Heidi J Welberry · Louisa R Jorm · Andrea L Schaffer · Sebastiano Barbieri · Benjumin Hsu · Mark F Harris · John Hall · Henry Brodaty

Objective: To identify functional performance trajectories and the characteristics of people who receive inpatient geriatric rehabilitation after hospital admissions. Design, setting, participants: REStORing health of acutely unwell adulTs (RESORT) is an observational, prospective, longitudinal inception cohort study of consecutive patients admitted to geriatric rehabilitation wards at the Royal Melbourne Hospital. Recruitment commenced on 15 October 2017. Main outcome measures: Functional performance, assessed with the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales two weeks before acute hospitalisation, on admission to and discharge from geriatric rehabilitation, and three months after discharge from geriatric rehabilitation. Results: A total of 618 rehabilitation patients were included in our analysis. For each of the two scales, three distinct functional performance trajectories were identified by latent class growth modelling: poor at baseline and 3‐month follow‐up (remained poor: ADL, 6.6% of patients; IADL, 42%), good at baseline but poor recovery (deteriorated: ADL, 33%; IADL, 20%), and good at baseline and good recovery (recovered: ADL, 60%; IADL, 35%). Higher Clinical Frailty Scale (CFS) score (v recovered, per point: odds ratio [OR], 2.51; 95% CI, 1.64–3.84) and cognitive impairment (OR, 6.33; 95% CI, 2.09–19.1) were associated with greater likelihood of remaining poor in ADL, and also with deterioration (CFS score: OR, 1.76; 95% CI, 1.45–2.13; cognitive impairment: OR, 1.87; 95% CI, 1.24–2.82). Higher CFS score (OR, 1.64; 95% CI, 1.37–1.97) and cognitive impairment (OR, 3.60; 95% CI, 2.31–5.61) were associated with remaining poor in IADL, and higher CFS score was also associated with deterioration (OR, 1.63; 95% CI, 1.33–1.99). Conclusions: Based on ADL assessments, most people who underwent inpatient geriatric rehabilitation regained their baseline functional performance. As higher CFS score and cognitive impairment were associated with poorer functional recovery, assessing frailty and cognition at hospital admission could assist intervention and discharge planning.

Cheng Hwee Soh · Esmee M Reijnierse · Camilla Tuttle · Celia Marston · Rose Goonan · Wen Kwang Lim · Andrea B Maier

To the Editor: We read the recent article from Haines and colleagues1 with interest and noted that it is featured on the front cover of the print version of the Journal. We agree that the Bupa model for provision of general practitioner services to residents of aged care facilities has promise, as illustrated by this study. However, we wish to point out that, despite these promising findings, this Bupa model has been terminated. The arrangement at the time of the Haines study (2012–2014), whereby GPs were employed by the company as part of a broader care model to provide medical services to residents of Bupa aged care facilities, no longer exists — as known among GPs and in the industry. That care model was reviewed and Bupa GPs were taken off salary when it was observed that GP Medicare billings did not match or exceeded their income. They were advised that they could continue only as contractors, with financial reimbursement being made through their Medicare billings alone. A handful of GPs apparently have remained on salary and they are those who are able to ensure that their billings cover their income. Most GPs chose to sever their ties once the focus of the company shifted. Some remain as contractors, with the acknowledgement that their relationship within the care home has changed. The responsibilities of education, meeting attendance and audits, which are not eligible for a Medicare rebate, are no longer performed. The termination of Bupa GPs as salaried employees coincided with other changes within the care staff structure. We interpret this to mean that promising models of practice that may improve the health of people living in residential aged care facilities can be compromised by corporate decision making that has motivations in addition to, or even at variance with, provision of good health care. Our interpretation is based on the contamination‐adjusted intention‐to‐treat analyses presented by Haines and colleagues.

Ian D Cameron · Helen Steinke · Susan E Kurrle

To the Editor: In a recent MJA article, Dyer and colleagues1 stated, “Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations”. However, the Australian numbers quoted are not comparable to the other 31 countries in the Organisation for Economic Co‐operation and Development (OECD) database.2 The “almost 20% of the population aged ≥ 80” refers to all persons in residential aged care at some time over the course of a year, whereas other countries mainly report point‐in‐time data. Only two countries (Australia and Greece) submitted data relating to residents over an entire one‐year period. In 2018, the Australian point‐in‐time rate for people aged ≥ 80 years was 13.9%.3 Point‐in‐time or census data are the appropriate numerator for calculating age‐specific usage rates for residential care, the standard method used in Australia for national purposes and the most common metric internationally. For people aged ≥ 65 years, the point‐in‐time rate was 4.5%4 rather than the 6.0% reported by Dyer et al. This is the difference between the 174 875 residents aged ≥ 65 years living in residential aged care at 30 June 2018 and the 234 617 who had lived in residential aged care during the 2017–18 financial year. For residents aged ≥ 80 years, the comparable figures were 137 537 (point‐in‐time) and 186 952 (the financial year).3 The Box presents statistics from the OECD countries used by Dyer and colleagues but incorporating point‐in‐time data for Australia.3,4,5 For persons aged ≥ 65 years, Switzerland has the highest rate at 5.6%. Seven countries then pack closely in between Australia (4.5%) and Denmark (3.9%). Given OECD data have inevitable limitations for comparative purposes, based on differences in national systems and reporting, these seven countries have similar levels of use. For people aged ≥ 80 years, rates are highest in Switzerland (16%), New Zealand (14%) and Australia (13.9%). Four additional countries sit close behind: the Netherlands, Sweden, Denmark and Canada, all in the 12.3–12.7% range. Nationally, the accurate 2018 usage rates for Australia are 4.5% for people aged ≥ 65 years and 13.9% for those aged ≥ 80 years. Internationally, Australia is a relatively high provider of residential aged care, but there are a number of countries with similar or higher levels of provision. Although there is insufficient evidence to claim that Australia is over‐reliant on residential care, the authors’ argument for increased investment in community‐based care is nonetheless an important one. Box – People aged ≥ 65 and ≥ 80 years using long term care as a percentage of total age group — international comparison of selected Organisation for Economic Co‐operation and Development (OECD) countries (2018) Percentage of people aged ≥ 65 years Percentage of people aged ≥ 80 years Switzerland 5.6% 16.0% New Zealand 4.3% 14.0% Australia 4.5% 13.9% The Netherlands 4.2% 12.7% Denmark 3.9% 12.7% Sweden 4.3% 12.6% Canada 4.0% 12.3% Germany 4.1% 10.7% Korea 2.7% 9.0% Japan 2.6% 7.2% United States 2.4% 6.1% Poland 0.8% 1.6% Data sources: For Australia, point‐in‐time usage data were extracted from the Australian Institute of Health and Welfare GEN Aged Care Data;3 for all other countries, data were extracted from OECD Statistics.5 Data are for 2018, or the most recent OECD data available in the case of Denmark (2014), the Netherlands (2017) and the US (2016). OECD data definitions indicate the point in time for Canada, Germany, the Netherlands, Poland, Switzerland and the US, a one‐month reference period for New Zealand and Japan, and are inadequately specified for Denmark, Sweden and Korea.2

Diane M Gibson