Long-term Impact of Hip Fracture on the Use of Healthcare Resources: a Population-Based Study

Impact of major osteoporotic fractures on the use of healthcare resources in Catalonia, Spain

OBJECTIVES

To estimate the impact of first major osteoporotic fractures (MOF) on health resource use and healthcare expenditures in people aged ≥50 years in Catalonia, Spain.

DESIGN

Observational, retrospective study. The Catalan Health Surveillance System (CHSS) registry was used to obtain sociodemographic, clinical and expenditure data from all public centres in Catalonia (Spain).

SETTING AND PARTICIPANTS

Males and females aged ≥50 years who sustained a first major osteoporotic fracture between January 1, 2018, and December 31, 2020.

METHODS

Data on admissions to the emergency department, hospitalization and skilled nursing facilities, primary and specialized care visits, nonemergency medical transport, outpatient rehabilitation and pharmacy prescriptions were retrieved for each patient. Monthly and yearly mean usage rates, expenditure in euros (€) and incremental costs one and two years after fracture were calculated.

RESULTS

There were 64,403 patients with first MOF: 47,555 females and 16,848 males with a mean age (standard deviation) of 76.5 (12.0) years. The average annual expenditure increased from €4564 in the year before to €12,331 in the year following a hip fracture. For forearm fractures, the expenditure increased from €2511 to €4251, for vertebral fractures from €4146 to €6659, for pelvic fractures from €4442 to €7124, for humerus fractures from €3058 to €5992, and for multiple fractures from €4598 to €12,028. The average cost for overall fractures experienced a 110.3 % increase. The leading cause of health expenditure in the year following MOF was hospital admission. Expenditure in the second year post-fracture returned to pre-fracture levels. The use of some healthcare resources, especially visits to emergency services, increased in the prefracture month. Male sex, older age and high previous comorbidities were associated with a higher expenditure.

CONCLUSIONS

In people with a first MOF, healthcare expenditure doubled during the first-year post-facture, mostly in relation to inpatient care. The healthcare resource use increased during the previous month. This increase could potentially be attributed to the worsening of pre-existing comorbidities.

Economic impact of inflammatory bowel disease in Catalonia: a population-based analysis

Background

Inflammatory bowel disease (IBD) has a major economic impact on healthcare costs.

Objectives

The aim of this study was to evaluate the current healthcare expenditure associated with IBD in a population-wide study in Catalonia.

Design

Retrospective observational study.

Methods

All patients with IBD included in the Catalan Health Surveillance System (CHSS) were considered eligible. The CHSS compiles data on more than 7 million individuals in 2020 (34,823 with IBD). Data on the use of healthcare resources and its economic impact were extracted applying the International Classification of Diseases, 10th revision, Clinical Modification codes (ICD-10-CM codes). Health expenditure, comorbidities, and hospitalization were calculated according to the standard costs of each service provided by the Department of Health of the Catalan government. The data on the IBD population were compared with non-IBD population adjusted for age, sex, and income level. IBD costs were recorded separately for Crohn's disease (CD) and ulcerative colitis (UC).

Results

Prevalence of comorbidities was higher in patients with IBD than in those without. The risk of hospitalization was twice as high in the IBD population. The overall healthcare expenditure on IBD patients amounted to 164M€. The pharmacy cost represents the 60%. The average annual per capita expenditure on IBD patients was more than 3.4-fold higher (IBD 4200€, non-IBD 1200€). Average costs of UC were 3400€ and 5700€ for CD.

Conclusion

The risk of comorbidities was twice as high in patients with IBD and their use of healthcare resources was also higher than that of their non-IBD counterparts. Per capita healthcare expenditure was approximately 3.4 times higher in the population with IBD.

Trial registration

The study was not previously registered.

Understanding the long-term impact of incident osteoporotic fractures on healthcare utilization and costs in Korean postmenopausal women

This study provides long-term evidence that healthcare resource utilization and costs of care in women who experienced incident osteoporotic fractures remained higher than those in women without fractures over a span of 5 years. These findings emphasize the importance of early diagnostics and treatment for osteoporosis.

PURPOSE

To evaluate healthcare resource utilization (HCRU) and costs of care over 5 years after the incident osteoporotic fractures (OF) in postmenopausal women.

METHODS

We used data from the National Health Insurance Service databases 2011-2018. Women aged ≥ 50 years with incident OF (OF group) were matched to women without OF (non-OF group). HCRU (inpatient, outpatient, and emergency room [ER] visits) and costs of care (inpatient, outpatient, and ER visits) during the 5-year follow-up period were derived after propensity score matching (PSM). Additionally, we identified women with subsequent fractures within the first 2 years after the incident OF.

RESULTS

After PSM, 47,238 OF and 134,813 non-OF women were identified. HCRU rates and costs of care were highest in the first year after OF and decreased substantially, but remained higher in the OF group during the entire follow-up period. The increase in cumulative HCRU rates over 5 years was highest in inpatient admissions with ER visits (138% higher in OF vs non-OF). The cumulative total costs over 5 years were 73% higher in the OF group than in the non-OF group, which was mostly driven by inpatient costs. Trends were similar for women with subsequent fractures, but they generally showed higher HCRU and costs than those in the total OF group.

CONCLUSION

OF imposes a substantial and sustained economic burden on women, resulting in an approximately twofold increase in the cumulative cost over 5 years compared to women without fracture, which highlights the need for early diagnostics and treatment of osteoporosis.

[Functional recovery units state in orthogeriatrics according to data from the National Registry of Hip Fracture]

INTRODUCTION

The National Registry of Hip Fractures (RNFC) facilitates knowledge of hip fracture process in Spain to clinicians and managers and is useful to the reduction of the results variability, including the destination at discharge after the hip fracture.

OBJECTIVE

The aim of this study was to describe functional recovery units (URFs) use for patients with hip fracture included in the RNFC and to compare the results of the different autonomous communities (AC).

MATERIAL AND METHODS

An observational, prospective and multicenter study of several hospitals in Spain. Data from a RNFC cohort of patients admitted with hip fracture between 2017 and 2022 were analyzed, focusing on the location at discharge of the patients, specifically on transfer to the URF.

RESULTS

52,215 patients from 105 hospitals were analyzed, 9540 patients (18.1%) were transferred to URF upon discharge and 4595 (8.8%) remained in these units 30 days later, with a variable distribution between the different AC (0-49%) and variability of results in patients not recovering ambulation at 30 days (12.2-41.9%).

CONCLUSIONS

There is in orthogeriatric patient an unequal availability and use of URFs between different autonomous communities. The study of the usefulness of this resource can be of great value for decision-making in health policies.

Morbidity and Mortality Analysis in the Treatment of Intertrochanteric Hip Fracture with Two Fixation Systems: Dynamic Hip Screw (DHS) or Trochanteric Fixation Nail Advance (TFNA)

BACKGROUND

The aim of this study was to compare the clinical outcomes, complications, and mortality of patients with intertrochanteric hip fracture treated with dynamic hip screw (DHS) vs. trochanteric fixation nail advance (TFNA).

METHODS

We evaluated 152 patients with intertrochanteric fractures concerning age, sex, comorbidity, Charlson Index, preoperative gait, OTA/AO classification, time from fracture to surgery, blood loss, amount of blood replacement, changes in gait, full weight-bearing at hospital discharge, complications, and mortality. The final indicators encompassed the adverse effects linked to implants, postoperative complications, clinical healing or bone healing duration, and functional score.

RESULTS

The study included a total of 152 patients, out of which 78 (51%) received DHS treatment and 74 (49%) received TFNA treatment. The results of this study show that the TFNA group demonstrated superiority (p < 0.001). However, it should be noted that the TFNA group had a higher frequency of the most unstable fractures (AO 31 A3, p < 0.005). Full weight-bearing at discharge also decreased in patients with more unstable fractures (p = 0.005) and severe dementia (p = 0.027). Mortality was higher in the DHS group; however, a longer time from diagnosis to surgery was also observed in this group (p < 0.005).

CONCLUSIONS

The TFNA group has shown a higher success rate in achieving full weight-bearing at hospital discharge when treating trochanteric hip fractures. This makes it the preferred choice for treating unstable fractures in this region of the hip. Additionally, it is important to note that a longer time to surgery is associated with increased mortality in patients with hip fractures.

The Impact of Hip Fracture on Geriatric Care and Mortality Among Older Swedes: Mapping Care Trajectories and Their Determinants

In this study, we examined the impact of hip fractures on trajectories of home care, nursing home residence, and mortality among individuals aged 65 years or more and explored the impacts of living arrangements, cohabitation, frailty, and socioeconomic position on these trajectories. Based on a linkage of nationwide Swedish population registers, our study included 20,573 individuals with first hip fracture in 2014-2015. Care trajectories during the 2 years following the fracture were visualized and compared with those of 2 hip-fracture-free control groups drawn from the general population: age- and sex-matched controls and health-matched controls identified through propensity score matching. Multistate modeling was employed to identify sociodemographic and health-related factors associated with care trajectories among hip fracture patients. We found that hip fracture patients already had worse health than the general population before their fracture. However, when controlling for prefracture health, hip fractures still had a considerable impact on use of elder-care services and mortality. Comparisons with the health-matched controls suggest that hip fractures have an immediate, yet short-term, impact on care trajectories. Long-term care needs are largely attributable to poorer health profiles independent of the fracture itself. This emphasizes the importance of adequate comparison groups when examining the consequences of diseases which are often accompanied by other underlying health problems.

Improving hip fracture care in Spain: evolution of quality indicators in the Spanish National Hip Fracture Registry

This study was carried out to analyze the evolution of the quality indicators in the Spanish National Hip Fracture Registry, after disseminating a series of recommendations based on available clinical practice guidelines to the participating hospitals. Six of the seven proposed quality indicators showed a significant improvement.

PURPOSE

The Spanish National Hip Fracture Registry (RNFC) arises from the need to know the process and improve the quality of care. Our goal was to analyze the changes in the RNFC's quality indicators after an intervention based on disseminating specific recommendations among the participating hospitals, following available clinical practice guidelines.

METHODS

Study comparing before and after performing an intervention in hospitals participating in the RNFC. Data from the hospitals that registered cases in 2017, and that kept registering cases in 2019. Seven quality indicators were chosen, and a standard to be achieved for each indicator was proposed. The intervention consisted in the dissemination of 25 recommendations with practical measures to improve each quality indicator, based on available clinical practice guidelines, by drafting and publishing a scientific paper and sending it via email and printed cards. Fulfilment of each quality indicator was measured after carrying out the intervention.

RESULTS

Forty-three hospitals registered 2674 cases between January and May, 2017, and 8037 during 2019. The quality indicators chosen and the degree of compliance were (all with p<0.05): (1) surgery ≤48 h increased from 38.9 to 45.8%; (2) patients mobilised on the first postoperative day increased from 58.9 to 70.3%; (3) patients with anti-osteoporotic medication at discharge increased from 34.5 to 49.8%; (4) patients with calcium supplements at discharge increased from 48.7 to 62.8%; (5) patients with vitamin D supplements at discharge increased from 71.5 to 84.7%; (6) patients developing a grade >2 pressure ulcer during admission decreased from 6.5 to 5.0%; (7) patients able to move on their own at 1 month fell from 58.8 to 56.4%. More than 48% of hospitals improved the proposed indicators.

CONCLUSION

Establishing quality indicators and standards and intervening through the dissemination of specific recommendations to improve these indicators achieved an improvement in hospital performance results on a national level.

Performance of quantitative measures of multimorbidity: a population-based retrospective analysis

BACKGROUND

Multimorbidity measures are useful for resource planning, patient selection and prioritization, and factor adjustment in clinical practice, research, and benchmarking. We aimed to compare the explanatory performance of the adjusted morbidity group (GMA) index in predicting relevant healthcare outcomes with that of other quantitative measures of multimorbidity.

METHODS

The performance of multimorbidity measures was retrospectively assessed on anonymized records of the entire adult population of Catalonia (North-East Spain). Five quantitative measures of multimorbidity were added to a baseline model based on age, gender, and socioeconomic status: the Charlson index score, the count of chronic diseases according to three different proposals (i.e., the QOF, HCUP, and Karolinska institute), and the multimorbidity index score of the GMA tool. Outcomes included all-cause death, total and non-scheduled hospitalization, primary care and ER visits, medication use, admission to a skilled nursing facility for intermediate care, and high expenditure (time frame 2017). The analysis was performed on 10 subpopulations: all adults (i.e., aged > 17 years), people aged > 64 years, people aged > 64 years and institutionalized in a nursing home for long-term care, and people with specific diagnoses (e.g., ischemic heart disease, cirrhosis, dementia, diabetes mellitus, heart failure, chronic kidney disease, and chronic obstructive pulmonary disease). The explanatory performance was assessed using the area under the receiving operating curves (AUC-ROC) (main analysis) and three additional statistics (secondary analysis).

RESULTS

The adult population included 6,224,316 individuals. The addition of any of the multimorbidity measures to the baseline model increased the explanatory performance for all outcomes and subpopulations. All measurements performed better in the general adult population. The GMA index had higher performance and consistency across subpopulations than the rest of multimorbidity measures. The Charlson index stood out on explaining mortality, whereas measures based on exhaustive definitions of chronic diagnostic (e.g., HCUP and GMA) performed better than those using predefined lists of diagnostics (e.g., QOF or the Karolinska proposal).

CONCLUSIONS

The addition of multimorbidity measures to models for explaining healthcare outcomes increase the performance. The GMA index has high performance in explaining relevant healthcare outcomes and may be useful for clinical practice, resource planning, and public health research.

Characteristics and Service Utilization by Complex Chronic and Advanced Chronic Patients in Catalonia: A Retrospective Seven-Year Cohort-Based Study of an Implemented Chronic Care Program

The Chronic Care Program introduced in Catalonia in 2011 focuses on improving the identification and management of complex chronic (CCPs) and advanced chronic patients (ACPs) by implementing an individualized care model. Its first stage is their identification based on chronicity, difficult clinical management (i.e., complexity), and, in ACPs, limited life prognosis. Subsequent stages are individual evaluation and implementation of a shared personalized care plan. This retrospective study, including all CCPs and ACPs identified in Catalonia between 2013 and 2019, was aimed at describing the characteristics and healthcare service utilization among these patients. Data were obtained from an administrative database and included sociodemographic, clinical, and service utilization variables and morbidity-associated risk according to the Adjusted Morbidity Groups (GMA) stratification. During the study period, CCPs’ and ACPs’ prevalence increased and was higher in lower-income populations; most cases were women. CCPs and ACPs had all comorbidities at higher frequencies, higher utilization of healthcare services, and were more frequently at high risk (63% and 71%, respectively) than age-, sex-, and income level-adjusted non-CCP (23%) and non-ACP populations (30%). These results show effective identification of the program’s target population and demonstrate that CCPs and ACPs have a higher burden of multimorbidity and healthcare needs.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway

Background

Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients’ subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6–12 months from the index admission).

Methods

Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients’ age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo’s boroughs to control for supply-side and unobserved effects.

Results

The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23–0.76) of living in a nursing home at 6–12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF.

Conclusions

The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06703-x.

Effects of Home-Based Physical Exercise on Days at Home, Health Care Utilization, and Functional Independence Among Patients With Hip Fractures: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effects of a physical exercise program on days lived at home, the use and costs of health care and social services, mortality, and functional independence among patients with hip fractures.

DESIGN

Randomized controlled trial with a parallel 2-group design consisting of a 12-month intervention and 12-month registry follow-up.

SETTING

Home-based intervention.

PARTICIPANTS

Patients aged ≥60 years (N=121) with operated hip fracture and who were living at home were randomized into physical exercise (n=61) and usual care (n=60) groups.

INTERVENTIONS

Supervised physical exercise twice a week.

MAIN OUTCOME MEASURES

The primary outcome was the number of days lived at home over 24 months. Secondary outcomes were the use and costs of health care and social services, mortality over 24 months, and Functional Independence Measure (FIM) over 12 months.

RESULTS

Over 24 months, there was no significant difference between the groups in terms of days lived at home (incidence rate ratio, 1.01; 95% confidence interval [CI], 0.90-1.14) or mortality (hazard ratio, 1.01; 95% CI, 0.42-2.43). The mean total costs of health care and social services did not differ between the groups. The costs per person-year were 1.26-fold (95% CI, 0.87-1.86) greater in the physical exercise group than in the usual care group over 12 months and 1.08-fold (95% CI, 0.77-1.70) over 24 months. The mean difference between the change in FIM of the groups over 12 months was 4.5 points (95% CI, 0.5-8.5; P=.029) in favor of the physical exercise group.

CONCLUSIONS

Long-term home-based physical exercise had no effect on the number of days lived at home over 24 months among patients with hip fractures. The intervention was cost neutral over these 24 months. The FIM scores improved in both groups over 12 months, but the improvement was significantly greater in the physical exercise group than in the usual care group.

Predictive Model of Gait Recovery at One Month after Hip Fracture from a National Cohort of 25,607 Patients: The Hip Fracture Prognosis (HF-Prognosis) Tool

The aim of this study was to develop a predictive model of gait recovery after hip fracture. Data was obtained from a sample of 25,607 patients included in the Spanish National Hip Fracture Registry from 2017 to 2019. The primary outcome was recovery of the baseline level of ambulatory capacity. A logistic regression model was developed using 40% of the sample and the model was validated in the remaining 60% of the sample. The predictors introduced in the model were: age, prefracture gait independence, cognitive impairment, anesthetic risk, fracture type, operative delay, early postoperative mobilization, weight bearing, presence of pressure ulcers and destination at discharge. Five groups of patients or clusters were identified by their predicted probability of recovery, including the most common features of each. A probability threshold of 0.706 in the training set led to an accuracy of the model of 0.64 in the validation set. We present an acceptably accurate predictive model of gait recovery after hip fracture based on the patients’ individual characteristics. This model could aid clinicians to better target programs and interventions in this population.

What Factors Predict Adverse Discharge Disposition in Patients Older Than 60 Years Undergoing Lower-extremity Surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) Risk Score

BACKGROUND

Adverse discharge disposition, which is discharge to a long-term nursing home or skilled nursing facility is frequent and devastating in older patients after lower-extremity orthopaedic surgery. Predicting individual patient risk allows for preventive interventions to address modifiable risk factors and helps managing expectations. Despite a variety of risk prediction tools for perioperative morbidity in older patients, there is no tool available to predict successful recovery of a patient's ability to live independently in this highly vulnerable population.

QUESTIONS/PURPOSES

In this study, we asked: (1) What factors predict adverse discharge disposition in patients older than 60 years after lower-extremity surgery? (2) Can a prediction instrument incorporating these factors be applied to another patient population with reasonable accuracy? (3) How does the instrument compare with other predictions scores that account for frailty, comorbidities, or procedural risk alone?

METHODS

In this retrospective study at two competing New England university hospitals and Level 1 trauma centers with 673 and 1017 beds, respectively; 83% (19,961 of 24,095) of patients 60 years or older undergoing lower-extremity orthopaedic surgery were included. In all, 5% (1316 of 24,095) patients not living at home and 12% (2797 of 24,095) patients with missing data were excluded. All patients were living at home before surgery. The mean age was 72 ± 9 years, 60% (11,981 of 19,961) patients were female, 21% (4155 of 19,961) underwent fracture care, and 34% (6882 of 19,961) underwent elective joint replacements. Candidate predictors were tested in a multivariable logistic regression model for adverse discharge disposition in a development cohort of all 14,123 patients from the first hospital, and then included in a prediction instrument that was validated in all 5838 patients from the second hospital by calculating the area under the receiver operating characteristics curve (ROC-AUC).Thirty-eight percent (5360 of 14,262) of patients in the development cohort and 37% (2184 of 5910) of patients in the validation cohort had adverse discharge disposition. Score performance in predicting adverse discharge disposition was then compared with prediction scores considering frailty (modified Frailty Index-5 or mFI-5), comorbidities (Charlson Comorbidity Index or CCI), and procedural risks (Procedural Severity Scores for Morbidity and Mortality or PSS).

RESULTS

After controlling for potential confounders like BMI, cardiac, renal and pulmonary disease, we found that the most prominent factors were age older than 90 years (10 points), hip or knee surgery (7 or 8 points), fracture management (6 points), dementia (5 points), unmarried status (3 points), federally provided insurance (2 points), and low estimated household income based on ZIP code (1 point). Higher score values indicate a higher risk of adverse discharge disposition. The score comprised 19 variables, including socioeconomic characteristics, surgical management, and comorbidities with a cutoff value of ≥ 23 points. Score performance yielded an ROC-AUC of 0.85 (95% confidence interval 0.84 to 0.85) in the development and 0.72 (95% CI 0.71 to 0.73) in the independent validation cohort, indicating excellent and good discriminative ability. Performance of the instrument in predicting adverse discharge in the validation cohort was superior to the mFI-5, CCI, and PSS (ROC-AUC 0.72 versus 0.58, 0.57, and 0.57, respectively).

CONCLUSION

The Adverse Discharge in Older Patients after Lower Extremity Surgery (ADELES) score predicts adverse discharge disposition after lower-extremity surgery, reflecting loss of the ability to live independently. Its discriminative ability is better than instruments that consider frailty, comorbidities, or procedural risk alone. The ADELES score identifies modifiable risk factors, including general anesthesia and prolonged preoperative hospitalization, and should be used to streamline patient and family expectation management and improve shared decision making. Future studies need to evaluate the score in community hospitals and in institutions with different rates of adverse discharge disposition and lower income. A non-commercial calculator can be accessed at www.adeles-score.org.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Postoperative mortality after surgery for inflammatory bowel disease in the era of biological agents: A population-based study in Southern Europe

BACKGROUND

Despite the efficacy of biological agents, surgery is still required for a large percentage of patients with inflammatory bowel disease (IBD).

AIMS

To assess the postoperative mortality rates and associated risk factors in IBD patients in a population-based setting in the era of biological agents.

METHODS

This is a population-based longitudinal study including all patients diagnosed with IBD in Catalonia who underwent intestinal resection or colectomy between 2007 and 2016, identified from the Catalan Health Surveillance System database. Logistic regression was used to calculate the adjusted odds ratio for postoperative in-hospital and 30-day mortality. Data for Crohn's disease (CD) and ulcerative colitis (UC) were analysed separately.

RESULTS

A total of 1,660 interventions for CD (69%) and 738 for UC (31%) were performed at 55 centres. In-hospital and 30-day postoperative mortality rates were 2.1% and 2.5% for CD, and 5.4% and 6.4% for UC, respectively. In the multivariate logistic regression analysis, comorbidity was associated with in-hospital and 30-day postoperative mortality in CD and UC, whereas age was only associated with mortality in CD and a non-laparoscopic surgical approach with UC.

CONCLUSIONS

In the era of biologicals, the postoperative mortality rate for IBD depends mostly on co-morbidities and age.

What lies beneath: a retrospective, population-based cohort study investigating clinical and resource-use characteristics of institutionalized older people in Catalonia

Background

Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.

Methods

Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.

Results

This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p < 0.001 in all comparisons), IOP showed a higher annual mortality (20.46% vs. 3.13%), a larger number of chronic diseases (specially dementia: 46.47% vs. 4.58%), higher multimorbidity (15.2% vs. 4.2% with GMA of maximum complexity), and annual admissions to acute care (47.6% vs. 27.7%) and skilled nursing facilities (27.8% vs. 7.4%), mean length of hospital stay (10.0 vs. 7.2 days) and mean of medications taken (11.7 vs. 8.0).

Conclusions

There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.