Delayed discharge of elderly hospital patients--a study of bed-blockers in a health care district in Sweden

Study protocol for investigating the impact of community home modification services on hospital utilisation for fall injuries: a controlled longitudinal study using data linkage

INTRODUCTION

This study will evaluate the effectiveness of home adaptations, both in preventing hospital admissions due to falls for older people, and improving timely discharge. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and fall prevention.

METHODS AND ANALYSIS

All individuals living in Wales, UK, aged 60 years and over, will be included in the study using anonymised linked data from the Secure Anonymised Information Linkage Databank. We will use a national database of home modifications implemented by the charity organisation Care & Repair Cymru (C&R) from 2009 to 2017 to define an intervention cohort. We will use the electronic Frailty Index to assign individual levels of frailty (fit, mild, moderate or severe) and use these to create a comparator group (non-C&R) of people who have not received a C&R intervention. Coprimary outcomes will be quarterly numbers of emergency hospital admissions attributed to falls at home, and the associated length of stay. Secondary outcomes include the time in moving to a care home following a fall, and the indicative financial costs of care for individuals who had a fall. We will use appropriate multilevel generalised linear models to analyse the number of hospital admissions related to falls. We will use Cox proportional hazard models to compare the length of stay for fall-related hospital admissions and the time in moving to a care home between the C&R and non-C&R cohorts. We will assess the impact per frailty group, correct for population migration and adjust for confounding variables. Indicative costs will be calculated using financial codes for individual-level hospital stays. Results will provide evidence for services at the interface between health and social care, informing policies seeking to promote healthy ageing through prudent healthcare and prevention.

ETHICS AND DISSEMINATION

Information governance requirements for the use of record-linked data have been approved and only anonymised data will be used in our analysis. Our results will be submitted for publication in peer-reviewed journals. We will also work with lay members and the knowledge transfer team at Swansea University to create communication and dissemination materials on key findings.

Long-term care and hospital utilisation by older people: an analysis of substitution rates

Older people are intensive users of hospital and long-term care services. This paper explores the extent to which these services are substitutes. A small area analysis was used with both care home and (tariff cost-weighted) hospital utilisation for older people aggregated to electoral wards in England.Health and social-care structural equations were specified using a theoretical model. The estimation accounted for the skewed and censored nature of the data. For health utilisation, both a fixed effects instrumental variables GMM model and a generalised estimating equations (GEE) model were fitted, the later on a log dependent variable with predicted values of social care utilisation used to account for endogeneity (bootstrapping was used to derive standard errors). In addition to a GMM model, the social-care estimation used both two-part and tobit models (also with predicted health utilisation and bootstrapping).The results indicate that for each additional pound1 spent on care homes, hospital expenditure falls by pound0.35. Also, pound1 additional hospital spend corresponds to just over pound0.35 reduction on care home spend. With these cost substitution effects offsetting, a transfer of resources to care homes is efficient if the resultant outcome gain is greater than the outcome loss from reduced hospital use.

[Hospital at home for acutely ill older]

The aging of population uses to evolve suffering from chronic diseases, many times in pluripathological shaped, which may engender frailty, disability and, as a last term, dependence. The aggravation of those and/or the appearance of others acute processes become the old people into a regular patient of our hospitals. The hospital at home (HaH) has showed that it may play an important role in the provision of range hospital cares to these patients, unimpaired of efficacy and security; but with indubitable benefits within the scope of their comfort (physical, psychical) and in the field of their functional condition. Available technical means at the present day and the staff's professionalism from these units make easier that any serious illness, medical or surgical, will be subsidiary in this type of attention sometime during their hospital care process. The HaH permits a more efficient rationalization of sanitary resources and should play an important role in the longed for interconnection between primary attention and specialized one.

Long stay patients in Winnipeg acute care hospitals

Risk factors for long-stays (more than 30 days) in Winnipeg hospitals were identified, including sociodemographic, illness, and system characteristics. The largest determinant of length of stay was discharge destination; discharge to a nursing home increased length of stay by 173% and 89% for medical and surgical patients, respectively. Hospital of stay also made a big difference for patients discharged to nursing homes. Only 13% of long-stay patients were discharged to a nursing home; 52% were discharged home. Other factors which were associated with an extended length of stay included, hospitalization for stroke, cognitive impairment, rehabilitation therapy, PEG tube insertion, and inhospital fall.

A description of inappropriate hospital stays in selected in-patient services: a study of cases receiving social work services

The number of discharges (63,303) from a university-affiliated medical center in Israel were reviewed. Eight percent of cases in three departments rcceivcd social work services. Patients experiencing inappropriate hospital stay (discharge delay) and who received social work services were characterized and compared with social work clients not experiencing delay. Discharge delay patients differed from other social work clients on key sociodemographic variables. Patients admitted because of "injury" were significantly more likely to experience delay than patients admitted because of "illness." "Waiting for community/institutional resources" was the most common reason for delay and discharge to an institutional setting increased the likelihood of delayed discharge. High risk factors were department-specific and should be studied in context. Results suggested the limited but positive impact of hospital-community collaborative strategies in reducing the incidence of delay over time.

Measuring appropriate use of acute beds. A systematic review of methods and results

A systematic review of the methods used to assess appropriateness of acute bed use and the evidence on the scale of inappropriate use in different patient groups is presented. Issues of generalisability of the findings are also addressed. Criteria based tools are the accepted way of measuring inappropriate days of stay and admissions, although opinion based classification is very common. While a number of tools exist, few have been adequately tested for reliability and validity. The Appropriateness Evaluation Protocol (AEP) is the most commonly used tool, and has been tested more widely. It appears to be both reliable and valid. An estimated 29% of admissions to acute psychiatric may be inappropriate. Regarding days of care after admission, between 24 and 58% of stays were not judged to be appropriate for continued stay on an acute ward. The need for continued acute psychiatric care may become lower as patients experience continued stay in the acute setting. A lack of housing and community support was the most commonly cited reason preventing discharge. Rates of inappropriate use appear to be higher for older patients than for the general population. Wide variation in rates of inappropriate days of stay was found, but it may be safe to assume that inappropriate use is greater than 20% across a wide variety of settings. Reasons for older patients to remain in an acute hospital bed after medically necessary are typically moderate nursing care needs (i.e. long-term care). The estimates of inappropriate use in other groups was found to be highly variable. Before definitive conclusions on the inappropriate use of acute beds can be made, future research needs to take into account the methodological problems discussed here.

[Impact of aging on hospital caseload]

PURPOSE

The progressive ageing of the population has led to a rise in the number of hospital admissions among people older than 64 years. The present study analyses the impact of this phenomenon comparing the case-mix of patients older and younger than 65 years.

METHODS

An analysis of the case-mix of all patients admitted to two acute hospitals of Barcelona Spain has been performed using the minimum basic data set of hospital discharges during 1997. The patients were grouped according to diagnosis-related groups (DRG). The characteristics of disease severity and complexity (admissions through emergencies department, DRG average weight, Charlson comorbidity index, average length of stay adjusted by case-mix, percentage of patients with an abnormal length of stay, readmissions and mortality rates were compared between the group of patients of 0-64 years and the group of 65 years and over. A further analysis was carried out for three subgroups of the aged patient population: 65-74, 75-84 and > 84 years.

RESULTS

The patients group of 65 years and over presented, in comparison with the younger than 65 qulaction, a higher average weight (1.16 vs 0.96), a higher percentage of admissions through emergency department (49.2% vs 44.4%), more comorbidity (Charlson's Index of 0.98 vs 0.66), a higher average length of stay adjusted DRG (9.4 vs 8.1), a higher percentage of patients with an abnormal length of stay (4.7% vs 3.2%), a higher readmissions percentage (8.6% vs 7.5%) and a higher mortality (6.3% vs 1.6%). All observed differences between the two groups were statistically significant. The analysis of the three subgroups of patients of 65 years and over showed that the variables admissions through the emergency department, length of stay and rate of mortality were significantly related to ageing, while the factor of complexity of comorbidity remained stable for all the subgroup of patients.

CONCLUSIONS

The case-mix of patients older than 65 years presents some characteristics associated with a higher complexity, severity and comorbidity, which imply more hospitalization days in relation to younger patients. Hospitals and the health care system at large should design specific strategies to face the fast and progressive ageing of patients admitted to hospitals, since this means a relevant change of the case-mix and the profile of health care requirements.

Early discharge planning for elderly patients in acute hospitals--an intervention study

In an intervention study geriatrically orientated discharge planning was tested at an acute hospital in Uppsala, Sweden. The planning was initiated at an early stage in the care of patients above the age of 75. The geriatric approach implies that the elderly patient's medical, functional and psychosocial needs are taken into consideration. A team consisting of a geriatrician and a qualified district nurse was responsible for the discharge planning in consultation with the patients and their relatives. One health care district formed the intervention group, while two comparable districts became two control groups. The intervention proved to be effective, giving better utilization of acute hospital beds through reduced numbers of bed-blocking patients, shorter waiting times for bed-blockers and reduced expenditure for district health authorities who were financially liable for that group. This was true even when the cost of the intervention was included. The results show how vital it is that discharge planning initiated at an early stage becomes standard practice in the acute care of the elderly. Collaboration with the district nurse is necessary for continuity, exchange of information, optimal assessment of care requirements and planning for discharge and follow-up after return to the home. Geriatric consultation at an early stage in the care episode, with assessment of geriatric-medical factors and rehabilitation requirements can contribute to more efficient care and discharge planning, especially for patients "at risk" at the discharge. In times when economic incentives are gaining increasing significance, a balance must be struck between an efficient use of resources, by choosing the right type of care at the right time, and the needs of the patients, with their right to autonomy and a say in their own care.

'Bed-blockers': delayed discharge of hospital patients in a nationwide perspective in Sweden

Between 1989 and 1992 the number of 'bed-blocking' patients in Sweden decreased from 15 to 7% according to national registers containing approx. 4000 patients. Part of this reduction can be explained by the 1992 Elderly Reform, which placed economic responsibility for bed-blockers on municipalities. However, the decrease began before the economic reform, implying that other factors are also involved, such as access to alternative institutional beds and other forms of care. An in-depth study of one district has provided a description of these often elderly patients, their heavy hospital utilization both before and after the bed-blocking period and their mortality. Nearly half the patients were dead within a year. Bed-blocking is a poorly defined concept requiring urgent discussion. Other related topics to which attention should be drawn are the administrative costs of economic control systems and efficient utilization of public resources as a whole.