Original articlePrevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study
Introduction
Over the last decades, along with the aging of the population, an increase in the demand for medical services has been observed in developed countries. Older people are more prone to illnesses, often have a large burden of chronic diseases and require hospitalization more frequently than younger people. Therefore, the highest share of healthcare-designated resources is used for the care of older subjects [1], [2], [3]. Hospital admissions and hospital-stay rates increase with age, and are accompanied by a greater risk of adverse events, such as hospital-acquired infections, functional decline, in-hospital death and re-hospitalization [4], [5], [6]. Moreover, the population ageing along with the reduction in the number of hospital beds might broadly contribute to the consistent overcrowding of hospital wards [7]. It has been suggested that the number of preventable admissions might be an attractive healthcare system quality indicator [8] and represent an active target for cost containment strategies [9]. However, this approach is not widely accepted because of lack of validation studies, limited understanding of complex underlying contributors and questions regarding whether these hospitalizations are truly avoidable [10]. Given the complexities surrounding any assessment of avoidable hospitalizations, a potentially informative related concept is that of “inappropriate” admission, that is a hospitalization occurring when not clinically necessary, thereby preventable or avoidable [11]. However, hospital admission is ultimately a clinical decision made by the physician and the patient, with multifaceted influences including system pressures, legal concerns, hospital policy, patient's needs and general practice culture [12,13]. Physicians have reported to rely heavily on clinical gestalt over evidence-based protocols to prompt a hospital admission, and often consider a multidimensional patient assessment, including so-called “extra-medical” or “social” factors [14], in place of, or in addition to, a focused disease-specific evaluation.
From a clinical point of view, inappropriate hospitalizations are rarely without health and functional costs in older people [15,16]. Moreover, these admissions represent a relevant component in the complex dynamics contributing to hospital overcrowding. In fact, inappropriate hospitalizations, length of hospital stay (LOS), and bed occupation are crucial and inseparable issues that need to be dealt with in order to increase medical care quality within healthcare-provider institutions. Therefore, a better understanding of prevalence and determinants of these interrelated problems would be essential to update and improve healthcare organization.
In the present prospective study, we aimed to assess i) the rate and determinants of inappropriate hospitalizations in older people; ii) whether and to what extent inappropriate hospitalizations contribute to inappropriate hospital stay.
Section snippets
Study design and setting
This prospective observational multicentre cohort study was carried out on a random sample of consecutive patients aged 70 years or older visiting the Emergency Departments (ED) of two tertiary hospitals in Piemonte, northern Italy: the “A.O.U. Città della Salute e della Scienza di Torino – Molinette” hospital in Turin and the “A.O. S. Croce e Carle” hospital in Cuneo. The study was conducted according to the Recommendations Guiding Physicians in Biomedical Research Involving Human Subjects and
Results
During the study period 3779 subjects aged 70 years or older accessed the EDs of the two hospitals; 1501 were not enrolled because they were not admitted during the daily hours of active data collection. Among the remaining 2278 patients, 401 patients could not be recruited mainly because of absence of signed informed consent or incomplete data. A final sample of 1877 patients was thus included in the analysis. Mean age and gender distribution did not differ between enrolled and not enrolled
Discussion
This prospective observational study aimed to assess whether and to what extent inappropriate hospital admissions contribute to hospital overcrowding. Our findings showed that: i) less than 15% of hospital admissions were labelled as “clinically inappropriate”; ii) although “inappropriate admissions” had shorter LOS compared with appropriate admissions, they contributed to the greatest proportion of inappropriate hospital stay during the study period.
The incidence of inappropriate
Conclusions
Less than 15% of inappropriate hospital admissions contributed to the greatest proportion days of inappropriate hospital stay. Most of these admissions are accounted for by older patients who can no longer be managed at home. The BRASS scale might be a useful tool to identify community-dwelling older patients with poor cognitive and functional status who may benefit from an early planning of home and/or residential interventions and supports, which should be widely implemented to reduce ED
Funding
The authors have not used any extra-institutional funding.
Availability of Data and Material
All Authors had all access to the data in this work and approved the submission of the present manuscript. All material in this assignment is Authors’ own work and does not involve plagiarism. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Declaration of Competing Interest
The authors of this manuscript declare they have no conflict of interest to disclose.
Acknowledgments
G.I., E.B., R.P., B.S., G.C., M.S., G.F., S.R., G.L., F.R., E.L. and M.B. contributed to the conception and design of the study; G.C. and M.S. contributed to the collection of the data; G.F., S.R. and R.P. performed statistical analysis; G.I., E.B., R.P., B.S. and M.B. wrote the main manuscript text; G.I., E.B., R.P., B.S., G.C., M.S., G.F., S.R., G.L., F.R., E.L. and M.B. contributed to the revision and approval of the final manuscript.
References (53)
- et al.
Older adults in the emergency department: A systematic review of patterns of use, adverse outcomes, and effectiveness of interventions
Ann Emerg Med
(2002) - et al.
The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies
J Clin Epidemiol
(2008) - et al.
French multicenter evaluation of the appropriateness of admission to the emergency department of the over-80s
J Nutr Heal Aging
(2015) - et al.
A randomized controlled trial of a home hospital intervention for frail elderly demented patients: Behavioral disturbances and caregiver's stress
Arch Gerontol Geriatr
(2004) - et al.
Correlates of quality of life for individuals with dementia living at home: the role of home environment, caregiver, and patient-related characteristics
Am J Geriatr Psychiatry
(2014) - et al.
Measuring appropriate use of acute beds
Health Policy (New York)
(2000) - et al.
The effect of longevity on spending for acute and long-term care
N Engl J Med
(2000) - et al.
Determinants of emergency department visits by older adults: a systematic review
Acad Emerg Med
(2003) - et al.
Risk factors for early and late mortality in hospitalized older patients: the continuing importance of functional status
J Gerontol - Ser A Biol Sci Med Sci
(2003) - et al.
The elderly in the emergency department: a critical review of problems and solutions
Intern Emerg Med
(2007)
Adverse health outcomes after discharge from the emergency department - Incidence and risk factors in a veteran population
J Gen Intern Med
Pressure on hospitals has led to worse care for older patients
BMJ
Dual eligible beneficiaries and potentially avoidable hospitalizations
Centers Med. Medicaid Serv
Potentially preventable hospital and emergency department events: lessons from a large innovation project
Perm J
Inappropriate admissions: thoughts of patients and referring doctors
J R Soc Med
A qualitative study exploring the factors influencing admission to hospital from the emergency department
BMJ Open
Mapping out the emergency department disposition decision for high-acuity patients
Ann Emerg Med
Factors influencing hospital admission of non-critically Ill patients presenting to the emergency department: a cross-sectional study
J Gen Intern Med
Hospitalization, restricted activity, and the development of disability among older persons
J Am Med Assoc
The geometry of patient safety: horizontal and vertical approaches to the hazards of hospitalization
J Am Geriatr Soc
Reliability and validity of an Italian four-level emergency triage system
Emerg Med J
Progress in development of the index of ADL
Gerontologist
Assessment of older people: self-maintaining and instrumental activities of daily living
Gerontologist
Validation of the cumulative illness rating scale in a geriatric residential population
J Am Geriatr Soc
Palliative performance scale (PPS): a new tool
J Palliat Care
Cited by (2)
Post-discharge care needs of the older people with hospital-associated disability: A longitudinal study
2023, Journal of Clinical NursingDischarge Delay: How Can We Help Ourselves, Patients, and Families
2023, Professional Case Management