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

Brian Draper

B.Draper@unsw.edu.au

www.med.unsw.edu.au/adfoap