Original article
Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study

https://doi.org/10.1016/j.ejim.2021.04.006Get rights and content

Highlights

  • Hospitalization rate increases with age, along with greater risks of adverse events.

  • Clinical and economic burden of inappropriate hospitalizations on healthcare system.

  • Mainly accounted for by frail older patients no longer manageable at home.

  • Need for an improvement of home and residential interventions and supports.

Abstract

In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay.

This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting.

Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%).

Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients.

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)

  • S.N. Hastings et al.

    Adverse health outcomes after discharge from the emergency department - Incidence and risk factors in a veteran population

    J Gen Intern Med

    (2007)
  • N. Hawkes

    Pressure on hospitals has led to worse care for older patients

    BMJ

    (2012)
  • Health at a Glance 2019: OECD Indicators....
  • M. Segal

    Dual eligible beneficiaries and potentially avoidable hospitalizations

    Centers Med. Medicaid Serv

    (2011)
  • L.I. Solberg et al.

    Potentially preventable hospital and emergency department events: lessons from a large innovation project

    Perm J

    (2018)
  • J. Campbell

    Inappropriate admissions: thoughts of patients and referring doctors

    J R Soc Med

    (2001)
  • I. Pope et al.

    A qualitative study exploring the factors influencing admission to hospital from the emergency department

    BMJ Open

    (2017)
  • L.A. Calder et al.

    Mapping out the emergency department disposition decision for high-acuity patients

    Ann Emerg Med

    (2012)
  • A.E. Lewis Hunter et al.

    Factors influencing hospital admission of non-critically Ill patients presenting to the emergency department: a cross-sectional study

    J Gen Intern Med

    (2016)
  • T.M. Gill et al.

    Hospitalization, restricted activity, and the development of disability among older persons

    J Am Med Assoc

    (2004)
  • H.L. Wald

    The geometry of patient safety: horizontal and vertical approaches to the hazards of hospitalization

    J Am Geriatr Soc

    (2017)
  • N. Parenti et al.

    Reliability and validity of an Italian four-level emergency triage system

    Emerg Med J

    (2010)
  • S. Katz et al.

    Progress in development of the index of ADL

    Gerontologist

    (1970)
  • M.P. Lawton et al.

    Assessment of older people: self-maintaining and instrumental activities of daily living

    Gerontologist

    (1969)
  • P.A. Parmelee et al.

    Validation of the cumulative illness rating scale in a geriatric residential population

    J Am Geriatr Soc

    (1995)
  • F. Anderson et al.

    Palliative performance scale (PPS): a new tool

    J Palliat Care

    (1996)
  • View full text