Hogeveen Sophie, Hirdes John P, Heckman George, Keller Heather
McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada.
Centre for Integrated Care, St. Joseph's Health System, Toronto, Ontario, Canada.
J Am Geriatr Soc. 2023 Sep;71(9):2810-2821. doi: 10.1111/jgs.18382. Epub 2023 May 5.
Little is known about determinants of access to community-based geriatricians. The Geriatric 5Ms™ describe geriatricians' core competencies and inform referrals to specialists for older adults with complex needs. We explored the association of the Geriatric 5Ms™ and other characteristics with outpatient access to geriatricians by home care (HC) clients.
This was a population-based, retrospective cohort study of frail community-dwelling HC clients (≥60 years) with complex needs (n = 196,444). Health assessment information was linked to health services data in Ontario, Canada, 2012-2015. Multivariable generalized estimating equations were used to identify characteristics associated with geriatrician contact (≥1 visit in 90 days post-HC admission), including derived Geriatric 5Ms™ score, and predisposing, enabling, and need factors obtained from clinical assessments.
Only 5.2% of the cohort had outpatient geriatrician contact in Ontario, Canada. Derived Geriatric 5Ms™ score was associated with higher odds of contact, but the model had modest discriminatory power (c-statistic = 0.67). In the broader multivariable model, based on empirically included factors and adjusted for regional differences, age, worsening of decision-making, dementia, hallucinations, Parkinsonism, osteoporosis, and caregiver distress/institutionalization risk were associated with higher odds of geriatrician contact. Female sex, difficulties accessing home, impaired locomotion, recovery potential, hemiplegia/hemiparesis, and cancer, were associated with lower odds of contact. This model had good discriminatory power (c-statistic = 0.77).
Few frail, community-dwelling older adults receiving HC had any outpatient geriatrician contact. While the derived Geriatric 5Ms™ score was associated with contact, a broader empirical model performed better than the Geriatric 5Ms™ in predicting contact with an outpatient geriatrician. Contact was mainly driven by conditions common in older adults, but evidence suggests that geriatricians are not evaluating the most medically complex and unstable older adults in the community. These findings suggest a need to re-examine the referral process for geriatricians and the allocation of limited specialized resources.
关于获得社区老年病医生服务的决定因素，人们了解甚少。老年病5M™描述了老年病医生的核心能力，并为有复杂需求的老年人转诊至专科医生提供依据。我们探讨了老年病5M™及其他特征与居家护理（HC）患者门诊获得老年病医生服务之间的关联。
这是一项基于人群的回顾性队列研究，研究对象为有复杂需求的体弱社区居住HC患者（≥60岁）（n = 196,444）。2012年至2015年期间，健康评估信息与加拿大安大略省的卫生服务数据相关联。使用多变量广义估计方程来确定与老年病医生接触（HC入院后90天内≥1次就诊）相关的特征，包括推导的老年病5M™评分，以及从临床评估中获得的易患因素、促成因素和需求因素。
在加拿大安大略省，该队列中只有5.2%的患者有门诊老年病医生接触。推导的老年病5M™评分与更高的接触几率相关，但该模型的判别能力中等（c统计量 = 0.67）。在更广泛的多变量模型中，基于经验纳入的因素并针对地区差异进行调整后，年龄、决策能力恶化、痴呆、幻觉、帕金森症、骨质疏松症以及照顾者困扰/机构化风险与更高的老年病医生接触几率相关。女性、回家困难、行动能力受损、恢复潜力、偏瘫/半身不遂和癌症与更低的接触几率相关。该模型具有良好的判别能力（c统计量 = 0.77）。
很少有接受HC的体弱社区居住老年人有任何门诊老年病医生接触。虽然推导的老年病5M™评分与接触相关，但在预测与门诊老年病医生的接触方面，一个更广泛的经验模型比老年病5M™表现更好。接触主要由老年人常见的疾病驱动，但有证据表明老年病医生并未评估社区中医疗最复杂和最不稳定的老年人。这些发现表明需要重新审视老年病医生的转诊流程以及有限的专业资源分配。
