Brian Draper 1, Diane Gibson 2 Ann Peut 3, Rosemary Karmel 3,Charles Hudson 3, Le Anh Pham Lobb 3, Gail Brien 3, Phil Anderson 3.

Transcription

1 Brian Draper 1, Diane Gibson 2 Ann Peut 3, Rosemary Karmel 3,Charles Hudson 3, Le Anh Pham Lobb 3, Gail Brien 3, Phil Anderson 3. 1 University of NSW, 2 University of Canberra, 3 Australian Institute of Health & Welfare

2 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)

3 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

4 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)

5 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.

6 Which hospital service types/features produce better outcomes for people with dementia? Indicators of interest Hospital admission rate Rate of discharge to residential aged care Length of hospital stay Patient care outcomes (falls, complications, mortality) Patient dependency level on entry to RAC Rate of return to community after residential respite following hospitalisation

7 Hospital Dementia Services Project Study Outline Stream 1 Data linkage of administrative data Descriptive analysis Stream 4 Dissemination of findings Expert panel Stream 3 Data consolidation Statistical model specifications Multi-level modelling Stream 2a NSW fieldwork (hospital survey, key informant, interviews/discussions) Stream 2b Region service mapping

8 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?

9 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.

10 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

11 Data Linkage Admitted Patient Care Database Legend: Entering hospital Leaving hospital Transfer between hospitals Hospital period, admitting hospital Hospital period, transferred in hospital stay Hospital 1 1 hospital visit Hospital 2 acute acute rehab rehab x 1 multi-day hospital stay with - 4 hospital episodes - 1 hospital visit - 2 hospitals 4 hospital episodes

12 VARIABLES Demographics Diagnoses Procedures Length of Stay Discharge Outcomes Data for public patients 50+ (253,000 multi day stays)

13 Linkage 1 within APDC to create person-level hospital stay-based dataset APDC variables: - demographics - diagnoses - procedures - activities on injury - care/ transition dates Data for public patients 50+ (253,000) Linkage 2 APDC to RAC to identify moves into RAC RAC variables: - demographics - care/transition dates - dependency data Linkage 3 APDC/RAC dataset to ACAP data at the person level, to identify related ACAP assessments ACAP variables: - demographics - assessment dates - care: needs arrangements recommendations program approvals data

14 253,000 persons aged at least 50 years on 1July 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 years had dementia Majority of dementia patients were female (60.1%)

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16 Types of Dementia Specified for Patients by Age, NSW years years 85+ years Total N = 759 N = N = 8771 N = Dementia % n % n % n % n Alzheimer s disease Vascular dementia Other degenerative dementia Parkinson s disease Lewy Body dementia Alcohol dementia < Huntington s/hiv/cjd Other Dementia Dementia with Delirium Mixed Diagnoses Unspecified Dementia

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18 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%).

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20 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.

21 Mental & Behavioural Problems and Neurological disorders were more prominent in year olds Fractures (particularly femur), Urinary Tract Infections, and Lower Respiratory Infections more prominent in older age groups

22 Dementia* No Dementia Allied Health (Physiotherapy, social work, OT etc) 35% 20.7% Imaging Services 32.8% (Head CT Scans) (23.1%) Musculoskeletal Procedures 8.2% (Pelvis & Hip) (5.6%) Procedures on Digestive System 5.4% 13.1% Procedures on Cardiovascular System (Coronary artery) 2.2% (0.6%) 21.5% (8.3%) 9.6% (2.5%) 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.

23 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

24 AGE DEMENTIA NO DEMENTIA TOTAL Years Mean Days Median Days Mean Days Median Days Mean Days Median Days Total

25 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

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27 Higher 3 month readmission rates in dementia patients accentuated in patients aged (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+)

28 Outcome Dementia No Dementia (%) (%) 85+ (%) Total (%) (%) (%) 85+ (%) Total (%) Transfer to RACF * Transfer to Other Accommodation Transfer to Usual Accommodation * * Died * * All statistically significant at p<0.001 relative to No dementia group, age and sex adjusted

29 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

30 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

31 Brian Draper