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The impact of the COVID ‐19 pandemic on delivering post‐acute care in a low‐ to middle‐income country

2022; Wiley; Volume: 71; Issue: 3 Linguagem: Inglês

10.1111/jgs.18106

1532-5415

Márlon Juliano Romero Aliberti, Marcelo Rozenfeld Levites, Frederico Alberto Nogueira Berardo,

Family and Patient Care in Intensive Care Units

Post-acute care based on person-tailored and multidisciplinary approaches is increasingly important as populations age.1, 2 Almost half of American Medicare patients are referred to post-acute settings after hospitalization.3 Although some controversies remain, previous work suggests that these settings (e.g., long-term acute care hospitals, skilled nursing facilities, and inpatient rehabilitation facilities) can reduce hospital readmissions in high-income countries.2-4 However, developing countries still struggle to implement such settings.2 The coronavirus disease 2019 (COVID-19) pandemic has caused huge impacts on healthcare delivery and utilization.5 Post-acute care settings helped relieve overloaded acute hospitals.6 Flexibility in requirements for post-acute admissions opened opportunities to broaden such services for patients with various conditions and needs. The consequences of these changes are to be understood.5, 7 Therefore, we investigated differences in post-acute care admissions before and during the COVID-19 pandemic in Sao Paulo, Brazil. Understanding post-acute care attributes during health crises can encourage its development in resource-limited contexts.8 We conducted a retrospective cohort study using data from a large post-acute care provider with seven facilities (243 beds) in Sao Paulo, Brazil. This multicentric institution receives patients—from more than 40 hospitals—who have stabilized an acute event. A multidisciplinary team offers integrated approaches for patients with complex medical needs. The primary aims are to improve quality care, avoid readmissions, and facilitate the return to the community, bridging the gap between hospital and community settings (Figure 1). Each post-acute facility integrates various services—long-term acute care, intensive rehabilitation, and palliative care (Table S1 defines services and gives examples). We assessed data from consecutive admissions of patients aged ≥18 years at the seven post-acute facilities between July 2018 and October 2021, comprising 20 months before and after the pandemic was declared. We excluded readmissions already included in the study. The Research Ethics Committee of the University of Sao Paulo approved the study. We retrieved information from electronic medical records using forms registered by physicians and nurses upon patient admission. It comprised demographic factors, primary reason for referral, type of required service, and level of care complexity.9 We also documented relevant outcomes for post-acute care, including length of stay, discharge destination or death, and level of satisfaction with care received. We compared baseline and outcomes variables according to the study periods (pre- vs during the pandemic) and types of service. Our sample consisted of 866 participants (pre-pandemic = 434 and during the pandemic = 432) representing the entire Sao Paulo metropolitan area (Figure S1). Participants had a mean age of 72 ± 18 years, and 54% were female (Table 1). We found significant differences in admissions according to the study period. While long-term acute care comprised most pre-pandemic cases, intensive rehabilitation, and palliative care were the most common services during the pandemic (Table 1). The pandemic period was also associated with shorter stays and higher satisfaction levels than the pre-pandemic period. This shift occurred while maintaining a low rate of hospital readmissions and increasing discharges to home as opposed to death (Table 1). Regarding post-acute services, lengths of stay were lower, satisfaction higher, and discharges to home more frequent in patients referred for intensive rehabilitation compared to those referred for long-term acute care and palliative care (Table S2). It is noteworthy that death occurred in 90% of palliative care admissions. We demonstrated that the COVID-19 pandemic impacted the incipient post-acute care setting in Brazil. It has become more diverse—from long-term acute care to a comprehensive model also offering intensive rehabilitation and palliative care. This transformation accompanied improvements in meaningful outcomes for post-acute care settings—shorter stays, higher satisfaction levels, and more discharges to home. Of note, our readmission rates to acute wards, around 13%, were better than or equal to reports in higher-income countries.2-4 These recent changes have the potential to remain, bringing new perspectives for broader patient profiles requiring post-acute care in resource-limited areas.8, 10 Some caution is needed in interpreting our results. Our data represent the developing post-acute care in the Brazilian private health system. However, 75% of our population depends on public health without a systematic transitional care program. Although we found higher satisfaction levels during the pandemic, this finding might reflect that long-term acute care, more common before the pandemic, involves rarely satisfied patients. Moreover, the service shifts we observed probably reflected pressures to alleviate overloaded acute hospitals, which might have led to unintended consequences not captured by our preliminary data. For example, the pandemic has led to a massive increase in post-acute rehabilitation use in the United States.7 Yet, post-acute facilities are often poorly equipped and staffed to meet the needs of acutely ill patients, predisposing adverse outcomes.5, 6 In sum, navigating the COVID-19 pandemic has been a challenge and an opportunity to encourage innovative post-acute care settings. Future research combining detailed clinical and function measures can bring new insights as post-acute care grows in resource-limited contexts. Study concept and design, data analysis, data interpretation, and manuscript preparation: Márlon Juliano Romero Aliberti. Study concept, acquisition of data, data interpretation, and manuscript preparation: Marcelo Rozenfeld Levites and Frederico Alberto Nogueira Berardo. MJRA is supported by a scholarship from HCFMUSP with funds donated by Nubank under the #HCCOMVIDA scheme. The funder had no role in the design, methods, data acquisition, analysis, preparation, review, or approval of the manuscript and decision on its submission. The authors declare no conflicts of interest. The funder had no role in the design, methods, data acquisition, analysis, preparation, review, or approval of the manuscript and decision on its submission. Table S1. A detailed description of post-acute care services. Table S2. Characteristics and outcomes of post-acute care admissions according to the types of service. Figure S1. Distribution of the study population in the metropolitan area of Sao Paulo, according to postal code. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.