Brian Draper1, Diane Gibson2Ann Peut3, Rosemary Karmel3,Charles Hudson3, Le Anh Pham Lobb3, Gail Brien3 , Phil Anderson3.
1University of NSW, 2University of Canberra, 3Australian Institute of Health & Welfare
People with dementia are relatively high users of acute hospitals
In Australia the mean length of stay (LOS) for all hospital separations is 8.6 days, compared with a mean of 19.6 days for separations with any diagnosis of dementia and 30.1 days for separations with a principal diagnosis of dementia (AIHW 2007)
The relatively higher casemix complexity of patients with dementia contributes to longer hospital stay (King et al. 2006)
Hospitals can be dangerous places for people with dementia with complications related to falls, undernutrition, skin tears, polypharmacy, pressure areas, infections and deconditioning (Kurrle, 2006)
Multiple bed moves → distress, agitation, increased confusion
Hospital environments → disorientation & anxiety (Cunningham & Archibald, 2006)
Organisational focus on efficient, cure oriented treatment means needs of PWD not met
Well targeted and designed services have improved the quality of care for people with dementia (Hales et al. 2006; Foreman & Gardner 2005; Corbett et al. 2005; Nay et al. 2000).
Evaluation of the Innovative Pool Dementia Pilot revealed that outreach and community‐based specialist dementia services reduced the use of hospitals by people with dementia, leading to improved patient outcomes (Hales et al. 2006)
The research design involves the use of quantitative and qualitative methods for a spatial analysis of the impact of service structures and processes on care pathways and outcomes of people with dementia following a hospital stay.
Multilevel statistical models will be constructed to test for associations between patient outcomes and hospital dementia service levels.
Which hospital service types/features produce better outcomes for people with dementia?
Hospital admission rate
Indicators of interest
Length of hospital stay
Patient care outcomes (falls, complications, mortality)
Rate of discharge to residential aged care
Patient dependency level on entry to RAC
Rate of return to community after residential respite following hospitalisation
Data consolidation
Statistical model
specifications
Multi-level modelling
Stream 3
Dissemination of findings
Stream 4
Expert panel
NSW fieldwork (hospital survey, key informant, interviews/discussions)St
ream
2a
Region service mapping
Stre
am2b
Data linkage of administrative data
Stre
am 1 Descriptive
analysis
Hospital Dementia Services Project Study Outline
What happens to people with dementia in hospital (length of stay, falls, complications, transfers to another hospital or death)?
How does this compare to patients without dementia?
Do these patterns vary with age?
The group of interest was patients for whom dementia was recorded on at least one hospital stay from July 2005 to June 2007 as contributing significantly to the cost of hospital care, the criterion used by hospitals when coding medical records.
Person‐level hospital stay‐based dataset using a unique patient identifier derived by the Centre for Health Record Linkage (or CHeReL)
Combines related hospital episodes into a single completed hospital stay (i.e. from initial admission to final discharge from hospital, allowing for movement both within and between hospitals)
Reports on the full period of hospitalisation from admission to discharge as experienced by the patient, whereas national hospital data are most commonly reported in terms of separate ‘episodes of care’, whereby a person whose care type changes from acute care to rehabilitation and then to palliation in one hospital stay is reported in national statistics as three episodes of care (with three lengths of stay and so forth).
Integrates hospital stays involving transfers between hospitals, creating one record per patient from admission to final discharge.
Identifies re‐admissions by individuals
Hospital 2
Hospital 1
Entering hospital
Leaving hospital
Legend:
1 multi-day hospital stay with
- 4 hospital episodes- 1 hospital visit - 2 hospitals
Transfer between hospitals
Hospital period, admitting hospital
Hospital period, transferred in
acute
acute rehab
rehab x
hospital stay
4 hospital episodes
1 hospital visit
Data Linkage – Admitted Patient Care Database
VARIABLES Demographics Diagnoses Procedures Length of Stay Discharge Outcomes
Data for 2006–07 public patients 50+ (253,000 multi‐day stays)
Linkage 2 – APDC to RAC to identify moves into RACRAC variables: - demographics- care/transition dates- dependency
2006–07 data
Linkage 3 – APDC/RAC dataset to ACAP data at the person level, to identify related ACAP assessmentsACAP variables: - demographics- assessment dates- care:
needs arrangements recommendations program approvals
2006–07 data
Linkage 1 – within APDC to create person-level hospital stay-based datasetAPDC variables: - demographics- diagnoses- procedures- activities on injury- care/ transition datesData for 2006–07 public patients 50+ (253,000)
253,000 persons aged at least 50 years on 1 July 2006 had at least one multi‐day stay ending between 1 July 2006 and 30 June 2007 in one of the 222 public hospitals in NSW.
20,793 were diagnosed with dementia Dementia was aged related – 25% of patients aged 85+ had dementia, 0.9% of patients aged 50‐64 years had dementia
Majority of dementia patients were female (60.1%)
50-64 yearsN = 759
65-84 yearsN = 11263
85+ yearsN = 8771
TotalN = 20793
Dementia % n % n % n % n
Alzheimer’s disease 11.1 84 18.0 2028 14.4 1263 16.2 3375
Vascular dementia 5.7 43 6.3 705 4.2 369 5.4 1117
Other degenerative dementia 20.8 158 5.1 570 3.1 268 4.8 996
Parkinson’s disease 3.0 23 5.9 662 2.8 245 4.5 930
Lewy Body dementia 1.6 12 1.3 141 0.6 49 1.0 202
Alcohol dementia 20.8 158 0.9 106 0.0 < 5 1.3 266-270
Huntington’s/HIV/CJD 2.8 21 0.1 11 0.0 0 0.2 32
Other Dementia 3.3 25 2.3 255 1.5 129 2.0 409
Dementia with Delirium 1.7 13 3.2 365 4.3 374 3.6 752
Mixed Diagnoses 4.1 31 3.8 433 1.9 164 3.0 628
Unspecified Dementia 25.2 191 53.2 5987 67.3 5906 58.1 12084
Types of Dementia Specified for Patients by Age, NSW 2006-07
Only 6.4% of dementia admissions are primarily for dementia; more likely to happen in patients under 65 (7.5%)
Main categories of admissions for dementia patients were circulatory system (15%), respiratory system (12%), fractures (10%), other injury and poisoning (8%) and the digestive system (8%).
Dementia* No Dementia
Fractured Femur 6.0% 1.2%
Urinary Tract infection 6.0% 1.4%
Lower Respiratory Tract Infection 8.0% 3.7%
Head Injury 3.1% 1.1%
Stroke 3.2% 1.9%
Septicaemia 1.8% 0.7%
* All statistically significant at p<0.001 relative to ‘No dementia’ group, age and sex adjusted.
Mental & Behavioural Problems and Neurological disorders were more prominent in 50‐64 year olds
Fractures (particularly femur), Urinary Tract Infections, and Lower Respiratory Infections more prominent in older age groups
Dementia* No Dementia
Allied Health (Physiotherapy, social work, OT etc) 35% 20.7%
Imaging Services(Head CT Scans)
32.8%(23.1%)
21.5%(8.3%)
Musculoskeletal Procedures(Pelvis & Hip)
8.2%(5.6%)
9.6%(2.5%)
Procedures on Digestive System 5.4% 13.1%
Procedures on Cardiovascular System(Coronary artery)
2.2%(0.6%)
9.0%(4.5%)
Urinary Catheterisation 0.8% 0.4%
No Procedures 23.2% 27.7%
* All statistically significant at p<0.001 relative to ‘No dementia’ group, age and sex adjusted.
Use of allied health only significantly greater in dementia patients under 85 compared with non‐dementia
Procedures on hip & pelvis only significantly greater in dementia patients 65 years & over compared with non‐dementia
Head CT scans more common in dementia across the age range but accentuated in patients under 65
AGE DEMENTIA NO DEMENTIA TOTAL
Years Mean Days
Median Days
Mean Days
Median Days
Mean Days
Median Days
50‐64 20.7 6 6.9 3 7.1 3
65‐84 16.5 7 9.2 5 9.9 5
85+ 15.9 8 12.9 6 13.7 7
Total 16.5 7 8.9 4 9.6 4
Very long mean LOS in younger patients due to a small proportion having very long admissions
Perhaps driven by placement difficulties as 25% of long stay patients under 65 were transferred to RACF
We note that a higher proportion of younger patients were admitted with BPSD
Higher 3‐month readmission rates in dementia patients accentuated in patients aged 50‐64 (55%) compared with those without dementia of same age (29%)
Overall 12.4% of patients readmitted within 1 day, dementia has no effect on this
Older patients significantly more likely to be readmitted within 1 day (9.9% 50‐64, 12.9% 85+)
Outcome Dementia No Dementia
50‐64 (%)
65‐84 (%)
85+ (%)
Total (%)
50‐64 (%)
65‐84 (%)
85+ (%)
Total (%)
Transfer to RACF 8.2 18.1 22.4 19.4* 0.4 2.1 7.4 2.2
Transfer to OtherAccommodation
2.6 2.6 2.8 2.7* 0.4 0.7 1.7 0.7
Transfer to Usual Accommodation
84.5 71.7 65.0 69.6* 96.8 92.2 81.9 92.5
Died 4.7 7.6 9.7 8.3* 2.3 5.0 9.0 4.6
* All statistically significant at p<0.001 relative to ‘No dementia’ group, age and sex adjusted
Increased mortality in dementia patients accentuated in younger patients
Although dataset does not give cause of death, 26% of dementia patients < 65 that died admitted with respiratory condition, 18% with GIT condition & 12% with a neoplasm
Dementia patients are most frequently admitted with injuries and infections – significantly higher rates of hip fractures, UTIs and Lower Respiratory infections
Dementia patients have substantially worse outcomes of acute hospitalisation compared with non‐dementia patients
These poor outcomes are frequently most marked among patients under 65
Examination of Falls Prevention strategies and adequately staffed ‘Hospital in the Home’ treatment approaches should be considered to minimise hospital use