Discharging older people from hospital care
Exploring the characteristics of effective arrangements

Hospital discharge procedures for older people have always been an important issue for readers STUART PARKER continues the ECA series of articles produced by the Sheffield Institute of Studies on Ageing (SISA) and finds that effective discharge arrangements for older people might be expected to result in about 15 per cent fewer readmissions to hospital than usual care. He also discovers that a key issue in effectiveness is the discharge team’s ability to function across the hospital and community interface.

Hospital stays and the importance of safe and effective discharges for older people

In the developed world, older people now make up a large and increasing proportion of the population. The demographic transition is well established and population ‘greying’ is becoming a significant issue in many developing countries. In general, older people are at increased risk of disease, disability, financial and social deprivation. Key issues for the health, well-being and quality of life for older people include population-based strategies for healthy ageing, the organisation and delivery of primary-care services, hospital-based care, alternatives to acute hospital admission and effective transfers of care between in-patient and community settings.

Older people are frequently admitted to acute hospital care. In the USA, for example, the over 65s account for 36 per cent of hospital admissions and almost 50 per cent of hospital expenditure. For many older people, admission to an acute hospital is associated with a decline in physical function, which is not always recovered by the time of discharge, or even after discharge from in-patient hospital care. Iatrogenic deterioration (that caused by disease linked with medical examination/treatment) is not uncommon and with extended stays, both informal and formal patterns of support at home may be disrupted to such an extent that they make a return to independent living extremely difficult.

Working across the boundaries between health, social, hospital and community-care systems is perceived to be important, particularly where there is a risk of adverse outcomes from prolonged and unnecessary hospitalisation. In this context, organisation and delivery of effective arrangements for discharging older people from in-patient hospital care is of central concern. Hospital discharge arrangements are therefore a key issue in ensuring the safe and effective transfer of older people between in-patient hospital care, and community-based home care.

The process of examining ‘gold standard studies’

In healthcare systems around the world there is an increasing awareness that the introduction of health technologies must be based on scientific evidence.

This usually means evidence derived from scientific studies of the efficacy and effectiveness of specific interventions on health outcomes. These studies can take a number of forms, but the randomised controlled trial is often cited as the ‘gold standard’. In a randomised controlled trial, people who are in need of the conventional treatment or service are randomly assigned to receive either the conventional intervention or a new intervention, which is the intervention being tested.

Some health technologies have undergone more or less extensive evaluation in randomised controlled trials, which are often conducted independently of each other, and will contain more information between them than any one alone. The process of finding and systematically evaluating the results of randomised controlled trials to produce a summary overview has become known as systematic literature review. Systematic reviews attempt to bring the same level of rigour to reviewing research evidence as should be used in producing that research evidence in the first place.

A high-quality systematic review attempts to find all relevant studies and synthesise the findings from individual studies to produce an impartial summary of the findings.

Systematic literature review of the discharge of older people from in-patient hospital care

Arrangements for discharging older people from in-patient hospital care have recently been the subject of a systematic literature review, which was commissioned by the UK National Co-ordinating Centre for Health Technology Assessment¹. In that review, the aim was to provide a comprehensive retrieval of published and unpublished clinical trials relating to interventions to improve the discharge of older people from in-patient hospital care. Randomised controlled trials evaluating an intervention intended to modify discharge, which included patients over 65 years old experiencing discharge from in-patient hospital care undertaken in hospital, or in the community, were included in the review. Discharge from low technology healthcare environments (such as community or ‘cottage’ hospitals, outpatient or day care) were not included.

Reprints of all potentially relevant studies were obtained and subjected to a relevance and quality check before proceeding to data extraction. Data was extracted from all relevant randomised controlled trials. The search process included keyword searches of 24 electronic databases, hand searches of relevant journals, scanning of reference lists, citation searches of key papers, contact with organisations and individuals via the internet and through personal communication, and keyword searches on the internet.

This was not a small task. Overall, 6,972 articles were identified by searches of the literature databases and other means. After reading the titles, and in some cases an abstract of these articles, 320 proceeded to relevance and quality assessment. In order to reduce potential bias, these processes were carried out independently by two reviewers, and disagreements between these reviewers were resolved through discussion between themselves and with a larger research team. Seventy-six papers were identified and data extracted. During the process of data extraction (which was also carried out independently by two reviewers for each paper) the reviewers were blinded to non-essential details, which might have introduced bias, such as the names of the authors, the institution in which the research was performed and the author’s conclusions. Final synthesis of data was performed using 71 articles representing 54 randomised controlled trials, ten of which were from the UK. Five trials were excluded.

Findings of the review

Overall, the interventions at discharge were shown to be safe, with no significant difference in mortality between the novel discharge arrangements tested and usual care at three months after discharge (ten trials), six months (14 trials) or 12 months after discharge (14 trials). The length of in-patient hospital stay preceding the discharge arrangements under test was not significantly affected by the interventions (19 trials).

However, readmission to hospital was significantly reduced by intervention. The rate of readmission to hospital after a discharge using the interventions under test was reported in 35 trials. The ratio between the readmission rates for intervention and control groups rates was 0.85. This result is statistically significant, the probability of it having occurred by chance being less than 0.5 per cent. It implies that effective discharge arrangements might be expected to result in about 15 per cent fewer readmissions to hospital than usual care.

Interestingly, the effect of intervention at discharge did not seem to be dependent on whether the intervention was provided by a single professional or a multidisciplinary team. It seemed to be most apparent in interventions provided both in hospital and in the patient’s home, implying that the key issue in the effectiveness of these interventions is their ability function across the hospital/community interface.

The analysis was also performed by intervention type. This analysis revealed that the evidence supporting specific interventions in discharging older people from in-patient hospital care is quite heterogeneous. It includes a number of randomised controlled trials of interventions based on the principles of comprehensive geriatric assessment, which are generally delivered by a multidisciplinary team of healthcare professionals, where effective co-ordination of discharge across the hospital/community interface is part of a package of care, including assessment and care recommendation in multiple domains. It includes interventions which are tightly focused on achieving high quality discharge outcomes, which generally involve a single individual (often a specialist or advanced practice nurse) co-ordinating a comprehensive, defined discharge process across the hospital/community interface, including the delivery of community-based services in support of the discharge arrangement. It also includes education interventions, which generally aim to empower older people to manage their own health and medications by providing information or more detailed education targeted at specific disease management.

It is tempting to speculate, given the marked heterogeneity of types of intervention that are shown to improve discharge outcomes, that a key factor determining effectiveness on reducing readmission rates might be other than the specific intervention type. For example, it may be that the organisation of care through multidisciplinary assessment, discharge co-ordination and education achieves a focus on the needs of the individual patient rather than the specific organisation or agency. However, this conclusion arises obliquely from the evidence rather than directly, so should be treated with some caution.

Acute hospital units and their discharge processes are only one element in a complex system of services serving the needs of older people in their homes, including community health and social services, primary care, rehabilitation, residential and nursing-home care, voluntary organisations, and the care of family and friends. Differences in the availability of community services (e.g. residential care beds) can have a marked and enduring impact on the capacity of acute units to discharge elderly patients. Consequently, the effectiveness of interventions to improve the speed and quality of discharge will depend to a large extent on the broader service context in which they take place. Interventions that are shown to work well in areas with well-resourced and efficient community-support services may have little or no impact where these services are inadequate or lacking.

Data synthesis

Random controlled trials in complex interventions, like the arrangements for discharging an older patient from in-patient hospital care, are not easy to perform well.

This area of healthcare is therefore not as well served as other, more easily circumscribed areas such as the use of drugs in specific diseases (such as heart disease or stroke) or as treatments for disease risk factors (such as high blood pressure, or high cholesterol levels). The process of systematic literature review has allowed us to identify the high quality trials that have been conducted in this area and to synthesise the data that they contain, exploring the evidence for common characteristics of effective interventions and developing new insights into the factors that may be most important in determining effectiveness in these processes.

References:

Parker, SM Peet, AM McPherson, AM Cannaby, K Abrams, R Baker, A Wilson, J Lindesay J, G Parker, DR Jones. A systematic review of discharge arrangements for older people. Health Technology Assessment 2002;6(4)

Stuart Parker trained in geriatric medicine and experimental gerontology. His research focuses on the application of health-services research methods to clinical practice, including the assessment of health status in older patients, hospital discharge, rehabilitation and long-term care. He is professor of health care for older people in the University of Sheffield and Honorary consultant physician at Barnsley District General Hospital. The co-ordinator of SISA articles for ECA and the key contact for readers is Doug Emery d.emery@sheffield.ac.uk