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Women's College Research Institute, Women's College Hospital, Toronto, Ontario, CanadaInstitute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaDepartment of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
Institute for Clinical Evaluative Sciences, Toronto, Ontario, CanadaInstitute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, CanadaLi Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, CanadaLawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
Home care services play an integral role in promoting independence, reducing hospital admission and readmission rates, and preventing or delaying nursing home admission among older adults. Despite important sex differences in functional status and use of services by recipients of home care, differences in home care performance measures by sex have not been examined.
To assess sex differences in the quality of publicly funded home care services in Ontario, Canada.
Validated, publicly reported home care quality indicators derived from the Resident Assessment Instrument for Home Care using the 2009 and 2010 Home Care Reporting System database were assessed for 119,795 Ontario home care clients aged 65 years and older. Unadjusted and risk-adjusted sex differences in performance were examined provincially and by health region.
In unadjusted analyses, there were sex differences in health outcomes on all indicators examined (decline or failure to improve in activities of daily living, cognitive decline, depressive symptoms, and pain control). After risk adjustment, differences were minimal. For example, in unadjusted analyses, 23.1% of women and 18.7% of men reported poorly controlled pain. After risk adjustment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of −0.4% (95% CI, −0.4% to −0.3%). Across health regions risk adjustment eliminated sex differences. There was 1.3-fold to 2.6-fold variation in performance on indicators across health regions.
After risk adjustment, no important sex differences in home care quality indicators were identified. Sizable regional variations observed indicate potential to improve home care outcomes for both women and men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex-specific strategies will likely be needed to improve home care quality.
Formal (i.e., publicly provided) home care services play an integral role in helping older adults preserve independence, remain in the community and delay or avoid institutionalization (
). Home care provides a range of services including nursing, personal support to assist with activities of daily living (ADLs) and instrumental ADLs, and rehabilitative therapy. This sector is challenged to meet the complex needs of an aging population. Home care can provide and connect older adults with interventions that slow the progression of functional and cognitive decline or provide adequate pain control (
). There are sex differences in the prevalence of common chronic conditions. For example, women have a higher prevalence of hypertension and arthritis compared with men, who have a higher prevalence of cardiovascular disease, stroke, and diabetes (
). These sex and gender differences influence the need for and outcomes of home care services.
Gender differences in quality of care and access to health care services have been well-documented across many conditions and health care settings. For example, women with diabetes or history of cardiovascular disease are less likely to have adequate cholesterol control than men (
Owing to sex differences in disease prevalence and multimorbidity, health and functional status, availability of caregivers, and financial and social circumstances, improving the quality of home care services will require addressing the specific needs of women and men. To our knowledge, no prior studies have assessed sex and gender differences in home care quality. Publicly reported home care quality indicators in both the United States and Canada are not stratified by sex. Thus, it is unknown whether there are disparities in home care performance associated with sex, and the extent to which home care services meet the specific needs of both older women and men. We therefore examined sex differences in the quality and outcomes of home care services using previously validated and publicly reported home care quality indicators. We assessed decline or failure to improve in ADL functioning, decline in cognitive functioning, depressive symptoms, and pain control. We also sought to determine whether there was regional variation in performance on these indicators associated with sex.
This retrospective cohort study used the Home Care Reporting System (HCRS) database from Ontario, Canada. Ontario is Canada's largest province with more than 13 million residents, nearly 2 million of whom are over the age of 65. The province is divided into 14 health planning regions or Local Health Integration Network (LHIN). Publicly funded home care is delivered by home care agencies that are funded and coordinated by regional Community Care Access Centres (CCACs), which are aligned with the LHIN boundaries. There are 14 CCACs in Ontario (
) and is used for care planning, funding, and quality measurement purposes. The RAI-HC includes items on physical functioning, cognitive performance, and clinical diagnoses that are used to calculate outcome measurements (such as those for mood and physical functioning) (
The study's population consists of 119,795 Ontario women and men 65 years and older, who were receiving long-stay home care services and assessed by CCAC care coordinators during the study period. Long-stay home care service use was defined as receipt of home care for 60 days or more.
The quality indictors used in this study were derived from the RAI-HC which is used in Canada, the United States (including by the Department of Veterans Affairs), and internationally (
), provide a valid and reliable means to evaluate home care with respect to effectiveness (keeping people healthy at home), safety (keeping people safe at home), population health (keeping population healthy at home) and accessibility (access to care and services) (
The quality indicators examined in this study were 1) decline or failure to improve in ADL functioning, 2) decline in cognitive functioning, 3) depressive symptoms, and 4) inadequate pain control. These four indicators were chosen for reporting in the POWER study, a comprehensive women's health equity report in Ontario, Canada. Indicator selection was done using a rigorous modified Delphi panel process for inclusion using structured criteria including their relevance to assessing disparities associated with gender and socioeconomic position (
). The first two quality indicators measure change over two assessments (typically done about 6 months apart), and the second two indicators measure symptom burden at one assessment. These outcomes have been previously validated (
Covariates/Confounders Used in Risk-Adjusted Models
Decline or failure to improve on ADL long form
Numerator: Recipients with some impairment on ADL long form who failed to improve between previous and most recent assessment or recipients who have a new ADL impairment based on ADL long form Denominator: All recipients with at least one reassessment who are not palliative on initial assessment
Difficulty in transfer, cognitive impairment (Cognitive Performance Scale)
Decline in cognitive function (measured using the Cognitive Performance Scale) (
Numerator: Recipients who have experienced a decline in cognitive performance between previous and most recent assessment or recipients who experience new cognitive impairment Denominator: All long-term recipients with at least one re-assessment
Diagnosis of dementia, bowel incontinence Aged ≥75 years
Numerator: Any recipient with sad mood on most recent assessment and ≥2 symptoms of functional depression are exhibited ≤5 days a week or daily or almost daily Denominator: All recipients
Short-term memory problem Recipient feels he/she has poor health, flare-up of recurrent or chronic problem, primary caregiver expresses feelings of distress, anger or depression, aged ≥75 years
Numerator: Number of recipients who have pain and are receiving inadequate pain control Denominator: All recipients having pain on most recent assessment
Decline or failure to improve in ADL function was measured as same or worsened ADL performance on the ADL long form relative to performance on the assessment immediately prior (usually approximately 6 months prior) (
). Decline in cognitive function was measured by the Cognitive Performance Scale at two time points during the 2009–2010 data collection cycle. The Cognitive Performance Scale was originally developed for the nursing home RAI assessment and has been incorporated into the RAI-HC (
). Decline in cognitive function was measured as recipients who have experienced a decline in cognitive performance between previous and most recent assessment or recipients who experience new cognitive impairment (
). There are clinical interventions to treat reversible causes of cognitive impairment (i.e., depression, anemia, hypothyroidism, infection) and medications that can improve or maintain functioning among those with mild to moderate cognitive impairment. This indicator was chosen because individuals with mild or moderate impairment should receive the needed supports and treatment to slow decline.
The quality indicators depressive symptoms and inadequate pain control were based on the most recent assessment. Depressive symptoms were measured by reports of sad mood and at least two symptoms of functional depression exhibited up to 5 days a week, almost daily, or daily (
). Symptoms of functional depression include items such as a feeling of sadness or being depressed, recurrent crying or tearfulness, withdrawal from activities of interest, and reduced social interaction (
Rates for each indicator were calculated to determine performance on each measure, where better home care quality is associated with a lower rate. The home care recipient's postal code was used to stratify by LHIN. All analyses, at both provincial and LHIN levels, were stratified by sex. The unadjusted rates were calculated for each quality indicator using the crude numbers and reflect the observed raw scores. Risk-adjusted rates were calculated using the multivariable regression models currently used for public reporting. Risk adjusters for each indicator are shown in Table 1. All analyses were conducted by the Canadian Institute for Health Information and were performed using SAS version 9.2. This study was approved by the research ethics boards of Sunnybrook Health Sciences Centre and St. Michael's Hospital both in Toronto, Ontario, Canada.
Of the 119,795 Ontario home care recipients, most were 80 years and older (70.6%) and women (69.7%). Before adjustment, 43.2% of women and 53.4% of men had decline or failure to improve in ADLs. In addition, 50.8% of women and 61.0% of men had a decline in cognitive functioning, 9.0% of women and 7.9% of men reported depressive symptoms, and 23.1% of women and 18.7% of men reported poorly controlled pain (Figure 1).
After risk adjustment, there were no important differences between women and men in outcomes for each indicator examined. After adjusting for difficulty in transfer and cognitive impairment, 45.7% of women and 44% of men showed decline or failure to improve in ADLs, with a difference of 1.7% (95% CI, 1.51%–1.88%). After adjusting for a diagnosis of dementia, bowel incontinence, and age 75 years and older, 50.8% of women and 50.5% of men showed decline in cognitive functioning, with a difference of 1.92% (95% CI, 1.61%–2.22%). After adjusting for short-term memory problems, recipient perception of poor health, flare-up of recurrent or chronic problem, primary caregiver distress, anger or depression, and age 75 years or older, 11.9% of women and 11% of men reported depressive symptoms, with a difference of 0.90% (95% CI, 0.82%–0.98%). After adjusting for cognitive impairment, 21.2% of women and 21.6% of men reported poorly controlled pain, with a difference of −0.4% (95% CI, −0.4% to −0.3%; Figure 1).
There was regional variation in risk-adjusted rates in outcomes (Table 2). Across health planning regions, there was a 1.5-fold variation in the rate for both women and men reporting a decline or failure to improve in ADL, with a greater percentage of women reporting a decline or failure to improve in ADL. There was a 1.4-fold variation in the rate for both women and men reporting a decline in cognitive functioning. There was a 2.4-fold variation in the rate among women and 2.6-fold variation in the rate among men reporting depressive symptoms with equal reporting between women and men across health planning regions. There was a 1.4-fold variation in the rate among women and 1.3-fold variation in the rate among men reporting inadequate pain control with equal reporting between women and men across health planning regions.
Table 2Risk-Adjusted Rates on Home Care Quality Indicators in Older Adults Across Ontario by Health Planning Region and Sex, April 1, 2009, Through March 31, 2010
Adjusted for short-term memory problem, recipient feels he/she has poor health, flare-up of recurrent or chronic problem, primary caregiver expresses feelings of distress, anger or depression, and aged ≥75 years.
All p-values across health planning regions and comparing women and men were less than 0.05.
∗ Adjusted for difficulty in transfer and cognitive impairment.
† Adjusted for diagnosis of dementia, bowel incontinence and aged ≥75 years.
‡ Adjusted for short-term memory problem, recipient feels he/she has poor health, flare-up of recurrent or chronic problem, primary caregiver expresses feelings of distress, anger or depression, and aged ≥75 years.
Important sex differences in unadjusted analyses were observed on all indicators examined (decline or failure to improve in ADL, cognitive decline, depressive symptoms, and pain control). In unadjusted analyses, women were more likely to experience depressive symptoms and poorly controlled pain, whereas men were more likely to experience a decline or failure to improve in ADL function and a decline in cognitive function. These differences in performance on unadjusted indicators reflect well-known sex and gender differences in health and functional status. However, these differences were nearly all eliminated in risk-adjusted models. The elimination of sex differences on these quality indicators by the factors included in risk adjustment models (such as level of cognitive impairment, difficulty in transfer, primary caregiver distress, and anger or depression) provides important insights into the care of these individuals. These findings can be used to inform gender-sensitive quality improvement interventions aimed at optimizing outcomes in home care for both women and men.
Quality indicators are used for different purposes. When used for quality improvement, the unadjusted differences reflect important differences in need among the populations served. Improving health outcomes requires interventions that address these differences. Risk adjustment, although required to compare quality of care among providers in a fair manner, may mask important sex and gender differences that need to be addressed to optimize care. For example, our study found that more women experience inadequately controlled pain and more men experience a decline in cognitive function. Furthermore, these indicators were developed to measure the performance of home care agencies. It is the responsibility of these agencies to assess patients and provide the needed services to optimize functioning and prevent decline. Therefore, on a population basis, these indicators reflect the overall quality of care and appropriateness of services provided. An agency that performs poorly on these indicators may need to reassess the mix of services they are providing.
Women comprise the majority of home care recipients and this difference increases with age. Women are more likely to live alone or be caregivers influencing their need for services (
). Women comprised 69.7% the study's population (83,497 women and 36,298 men). Therefore, improving the quality and outcomes of home care services at the population level will require specifically addressing the needs of older women. Given differences between older women and men receiving home care services in patterns of illness, health and functional status, and social and economic circumstances, it is likely that gender sensitive interventions will be needed to optimize health outcomes.
Within individual health planning regions, risk adjustment eliminated sex differences in performance on the quality indicators. However, important variations in quality indicators across regions were observed for all indicators examined. For example, within older female home care recipients, reporting of depressive symptoms differed by 2.4-fold, depending on the region in which an individual received home care. Furthermore, Region 8 had the highest percentage of home care recipients reporting depressive symptoms and inadequately controlled pain in both women and men. Region 5 had the highest percentage of home care recipients reporting decline or failure to improve in ADLs and cognitive decline in both women and men. Thus, although a gold standard level of optimal performance on these indicators is not known, observed differences suggest considerable potential to improve care.
Differences between regions in geography, populations, and availability of resources contribute to the regional variations observed. Of the 14 regions, 2 are urban, 5 are rural, and 7 are mixed (
). Across regions other challenges, including travel time, and the availability of health care personnel and services influence the types, mix, and intensity of services provided, as well as health outcomes. Ontario, which covers approximately 416,000 square miles, is larger than France and there are geographic differences in approaches to health and health care in urban, rural, and remote communities. Home care agencies are responsible for their budgets and allocation of services. These quality indicators provide important information that can be used to target and tailor interventions locally to optimize care. Stratifying these indicators by sex can help agencies to address the specific needs of older women and men. Gender differences associated with geography and ethnicity will need to be addressed in designing interventions to improve home care performance.
Home care is one component of the continuum of care provided to the community-dwelling older population. Outcomes of care for the indicators assessed will also be influenced by the clinical care provided. Communication and coordination between home care and primary care is not always present, or when present often suboptimal (
). Integration and coordination of care between primary care and home care is currently a target of health care reform and could play an important role in optimizing outcomes. Integrated care models have been proposed and seek to improve the communication between home care and primary care to better address the needs of home care recipients (
). A Canadian study that linked primary care physicians with home care coordinators for defined communities resulted in better anticipatory care with fewer health crises and improved patient experience with no significant increase cost to the health care system (
). A better understanding is needed of the contribution of care coordination across settings of care to optimize outcomes assessed.
A number of limitations are noted. The RAI-HC quality indicators are outcome measures and we do not have information on the processes of care that led to these outcomes. Thus, these analyses do not provide information on the factors that lead to variation in quality of care across health regions. Future work should examine the relationship between performance on these indicators and services received. Second, this study focused on long-stay home care recipients and we do not examine outcomes in short-stay recipients, including individuals receiving home services for post-acute care or rehabilitative purposes. Third, we do not have data on supplemental, privately provided home care services or informal care that could potentially influence these outcomes. Fourth, the depression and pain indicators are based on the most recent assessment to reflect outcomes of care. Additional indicators that measure change in these symptoms would be of value. Finally, the RAI-HC was not developed to assess gender disparities, and may not capture important factors that influence gender differences in home care. These indicators were selected for inclusion in the POWER Study because of their importance and relevance to the health of older women (
). More work is needed to develop gender sensitive indicators for home care. Despite these limitations, the RAI-HC has many strengths, and these indicators are used for public reporting both provincially and nationally in Canada. Many jurisdictions have also adopted the RAI-HC and collect clinical and administrative data similar to Ontario.
Implications for Policy and/or Practice
Home care plays an essential role in supporting community-dwelling older adults by providing services that maintain independence and delay or avoid institutionalization. Efforts to improve coordination and communication between primary care and home care are needed to improve care quality for older adults living in the community. Older women comprise the majority of long-stay home care users and have different needs than men. Sex differences in unadjusted analyses demonstrate the value of examining both unadjusted and adjusted outcomes and suggest sex specific strategies will likely be needed to improve home care quality.
Parts of this study are based on data, information, and analyses provided by the Canadian Institute for Health Information. However, the conclusions, opinions, and statements expressed herein are those of the authors and not necessarily those of the Canadian Institute for Health Information.
At the time that this study was conducted, Dr. Gruneir was a Scientist at Women's College Hospital but has since re-located to the University of Alberta.
Amanda T. Lo, MD, MSc, Department of Family and Community Medicine, University of Toronto. Her research interests include dementia, caregiver experiences and the role of primary care for older adults.
Andrea Gruneir, PhD, Department of Family Medicine, University of Alberta, Women's College Research, Institute, Women's College Hospital, Institute for Clinical Evaluative Sciences, and Institute for Health Policy, Management and Evaluation, University of Toronto. Her research area is health services use in older adults, especially long-term care services.
Susan E. Bronskill, PhD, Scientist & Program Lead, Health System Planning & Evaluation, Institute for Clinical Evaluative Sciences, and Assistant Professor, Institute of Health Policy, Management & Evaluation, University of Toronto. Her research interests include medication use in frail older adults, continuity of care in long-term care and home care, health services research.
Arlene S. Bierman, MD, MSc, Professor, Health Policy, Evaluation, and Management, Public Health, Nursing, and Medicine, at the University of Toronto, and Scientist, Li Ka Shing Knowledge Institute, St. Michael's Hospital. Her research aims at improving care for disadvantaged older adults.
Published online: April 15, 2015
Received in revised form:
Note the mailing address and phone number is for Dr. Bierman, if planning to mail or call, please indicate Attention: Dr. Bierman; otherwise if through e-mail correspondence it should be addressed to Dr. Lo.
Funding: This research was funded in part by the Project for an Ontario Women's Health Evidence-Based Report (POWER Study) which received funding from Echo: Improving Women's Health in Ontario, an agency of the Ontario Ministry of Health and Long-Term Care. No endorsement by ICES, Echo or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred. Dr. Bronskill was supported by a Canadian Institutes of Health Research (CIHR) New Investigator Award in the Area of Aging.