What use is made What use is made of acute hospital beds of acute hospital beds from aged care residentsfrom aged care residentsin Auckland, New Zealand? in Auckland, New Zealand?

Joanna Broad, Michal Boyd, Martin Connolly

Freemasons’ Department of Geriatric Medicine

University of Auckland, Auckland, New Zealand

RNZCGP Annual Conference,Auckland, September 2011

Residential aged care (RAC) in New Zealand

RAC for older people in New Zealand is classified by Health and Disability Services (Safety) Act 2001 as:

• private hospital care - for those who need 24-hour nursing or medical care

• rest home care - for those who are frail or need support, but not 24-hour nursing or medical services

Residential aged care in NZ is used by over 40% of those aged 65+ before death

Interest in hospitalisations by those living in RAC - why?

Concerns that population ageing will drive large increases in demand for hospital care, from people in communities and in RAC

Anecdotal reports of concern for numbers of hospital beds occupied by people from RAC, with hospital services stretched because of RAC residents

2010 projections show demand for RAC beds will rise 78 – 110 % by 2026 Grant Thornton 2010

RAC residents admitted can become disoriented, suffer adverse events, declines in function and long-term outcome

Evidence that improved care is possible within the facilities themselves

What is “known” of hospital use by those in RAC ?Compared with people living in the community,

RAC residents showed higher risk of hospitalisation (RR=1.39), injury (2.68), #NoF (3.96), death in hospital (2.58) Godden 2001

LTC residents (vs home-based care, & home in community) received less inpatient care, less ambulatory care, more physician care Wilson 2006

In Western Australia, 30+ transfers to ED per 100 RAC beds per year. 40+% not admitted Arendts 2010

23% of costs of hospitalisations from RAC are potentially avoidable Grabowski 2007

??

What is known of hospitalisations by those in RAC in NZ?

Our national hospitalisation records do not usually record where people live or arrive from

Available data about where they go when discharged is regarded as unreliable

no good evidence about use of acute care from RAC

??But, we had OPAL survey data for a full cohort of residents

at one point in time Broad 2011, Boyd 2011

Could track residents over time using NHI numbers

? Could provide useful hospitalisation information

Question: What use is made of acute hospital beds by people living in RAC settings?

• Briefly, complete survey of all facilities licensed to provide residential aged care in Auckland region, incl. NHI number

• Mortality & hospitalisations information from NZHIS, using NHI numbers to identify residents

• Can select those for acute unplanned admissions

• During analyses, can weight resident records to represent a one-year profile of residents within each facility, to provide population-wide view

• Full ethics approval

Method: OPAL survey of facilities licensed to provide RAC in Auckland

• Survey in September 2008 using same items as in 3 previous surveys over 20-year period

• included people living in rest homes, public & private long-stay hospitals (independent living units & retirement villages were not included)

• all facilities in wider Auckland region (3 DHBs)

• resident information recorded – demographic, stay information, care level, functional dependency, NHI number (no names)

Method: NHI hospitalisation data• merged hospitalisation data with survey data

• hospitalisations information from NZHIS– used NHI numbers to identify residents

– checked age & gender matched

– details include dates of all admissions & discharges, all recorded discharge diagnoses & procedures, & DRGs

– retained only acute unplanned admissions

• “joined” transfers into single sequence, used DRG code of first in sequence

• selected records of completed overnight hospital stays where date of admissions was before 10Sept09

• during analyses, weighted to represent resident population over 12 months

Cohort information

• 152 of 172 facilities (88%) OPAL participation• 6,839 forms (90%), representing 7,601 residents • 6,255 (91%) were matched (some no NHI #s)

Survey Population

No. facilities 152 172

No. beds 8,719 8,816

No. residents 6,839 7,601

Matched with NHI 6,255 -

Mortality in 12m:No. deaths 1,594

No. in-hospital deaths 306

Completed admissions - acute, unplanned:

No. residents admitted 1,166

No. hospital admissions during 12m 1,549 (9% “joined” from a sequence of stays)

No. hospital bed-days (incl. after 12m) 17,181

Outcomes in 6,255 residents matched, during 12 months post-OPAL

Residents, admissions & bed-days of population of RAC residents in Auckland, Sep08-Sep09

N residents Admissions Bed-days OPAL cohort with MoH matching 6,255 1,549 15,138

Est. OPAL cohort -inflated for non-matched 6,829 1,689 16,505

Est. RAC population -inflated for non-response 7,592 1,890 18,362

Est. thru RAC during 12 month period 9,057 2,165 20,543

Estimated admissions in population of RAC residents in Auckland, Sep08-Sep09

Counts

Residents in region 9,057

Residents with 1+ admits 1,658 (18%)

Admissions 2,165

meanTotals per stay

Bed-days in 12m 20,543 9.5

Cost-weights 4,272 2.0

Note: sequential stays are combined into a single stay, so are not comparable with usual data

Admissions for selected DRGs in population of RAC residents in Auckland, Sep08-Sep09

*N % bed-days%

Respiratory infection 161 7 1,018 5Hip & femur 125 6 2,393 12Heart failure 121 6 1,152 6Kidney & UTI 120 6 913 4Stroke 71 3 806 4Gastro-intestinal 66 3 581 3COPD 65 3 971 5Dementia 37 2 1,385 7Rehabilitation 36 2 871 4Mental disorders 14 1 648 3

* Note: Top 10 DRGs are here selected & sorted by number of admissions

Admissions for selected DRGs in population of RAC residents in Auckland, Sep08-Sep09

admission rate *meanmean

per 1000 person-years LOS cost-wt

Mental disorders 1.9 48 13.6Dementia 5.1 38 4.9Rehabilitation 5.0 24 3.5Hip & femur 17.4 19 5.4COPD 9.0 15 2.8Stroke 9.8 11 2.3Heart failure 16.7 10 1.6Kidney & UTI 16.6 8 1.4Respiratory infection 22.2 6 1.4Circulatory 10.8 5 1.3

* Note: Top 10 DRGs are here selected & sorted by length of stay

Number of bed-days in 12m

300

800

1300

1800

2300

2800

Number of admissions

0 50 100 150

Mental disorders

Dementia

Rehabilitation

Hip & femur

COPD

Stroke

Heart failure

Kidney & UTI

Cellulitis

Circulatory

Most expensive conditions, circles represent sum of cost-weights

Strengths• Prospective cohort

• Clear time points

• Good response rate

• Good matching rate

• Outcomes measured independently using routinely collected data, so study bias does not arise

Weaknesses• Use of weighting to

adjust for missing data assumes that those missed, or not matched, are similar to others

• Most data shown are estimates for the 12-month period, yet confidence intervals not calculated

• Potential exists for some admissions to be grouped with others to make larger DRG groups

Where does this lead? For the year Sept 2008-09, in Auckland• an estimated 9,000 RAC residents• ~2,200 acute hospital stays, ~ 6 per day• 30 admits per 100 occupied beds per year• 20,500 bed-days over the year

??A reduction in admissions from RAC of

10% could lead to ~2,050 bed-days saved pa15% could lead to ~3,000 bed-days saved pa

Most costly acute conditions include hip & femur, respiratory infections, heart failure, mental disorders, COPD, dementia, kidney & UTI, & stroke

Evidence that hospitalisations from RAC can be reduced through…

• multi-disciplinary team, integrated care approach Philiips 2000, Joseph 1998

• more skilled facility staff (assessment & early recognition) Konetza 2008, Kane 2003, Ouslander 2010, Szczepura 2008

• co-ordination of care by e.g. nurse practitioners Kane 2003

• better assessment of acute or sub-acute changes in condition Rantz 2004

• ability to obtain diagnostic tests & administer intravenous fluids Loeb 2006

• advanced care planning Kaplan 2006

• medication reviews Szczepura 2008

have been shown to reduce hospitalisations without negatively impacting resident care

Ambulatory sensitive admissions (ASH) i.e. potentially avoidable admissions• Usual definitions of ASH exclude those aged over 75yrs• Definitions typically include:

– congestive heart failure– pneumonia & respiratory infections– kidney & urinary tract infections– circulatory conditions including MI, stroke, IHD– fall or fracture– diabetes, nutrients & anemia, constipation

• To which we add:– skin tears, leg ulcer, cellulitis– dementia, depression– syncope, collapse, hypotension– dehydration, volume depletion & others

Aged Residential Care Hospital Utilisation Study (ARCHUS) – an RCT

• cluster randomised trial currently underway• complex package of supports & education to

facility staff:– initial stock-take assessment of care, incl.

benchmarking– provision of targeted education to facility nurses &

caregivers– multi-disciplinary team meetings including GP– ongoing access to specialist physician & nurse– clinical coaching for high-risk residents

• aim to reduce ASH admissions without negatively impacting residents’ care

Aged Residential Care Hospital Utilisation Study (ARCHUS) – in progress

• 36 RAC facilities in Auckland region• using staff of 3 DHBs• recruitment complete, intervention complete

April 2012, follow-up until November 2012, results 2013

• economic evaluation planned• feedback study of implementation planned

See poster for more information

Summary

• when weighted to represent the RAC population in Auckland, ~6 acute hospital admissions per day (not including ED presentations which did not lead to overnight admission)

• 30 admissions per 100 occupied beds in this cohort in 12-month period (Sept 2008-Sep2009)

• if this could be reduced by say 15%, ~46bed-days per month would be made available

• efforts to reduce admissions from RAC could focus on improving earlier recognition & improved care within facilities for any of the following:– hip & femur, respiratory infections, heart failure, mental

disorders, COPD, dementia, kidney & UTI, & stroke

Acknowledgements

The staff and managers of the facilities who completed forms.

Health Care Providers & the Association of Residential Care Homes, for support.

Funding 2008-09 Freemasons Roskill

Foundation2010-11 Health Research Council

of NZ.

Numbers of residents & admissions

RAC beds

residents

in OPAL

with matched NHI records

with any admission in 12m

with any acute admission

no. of admissions in matched residents

est. no of admissions in OPAL

est. no of admissions in OPAL population

est. no of admissions in RAC population

0100020003000400050006000700080009000

Mortality in cohort6mths 12mths

22mthsOverall 14% 25% 40%

Men 15% 28% 43%Women 13% 24% 39%

Aged under 65 yrs 6% 11% 16% 65-74 yrs 9% 18% 27% 75-84 yrs 12% 24% 37% 85-94 yrs 16% 28% 44%

95+ yrs 17% 36% 56%

Care typeRest home 8% 18% 32%Dementia 10% 23% 32%Other eg short stay 14% 19% 27%Psycho-geriatric 17% 24% 33%Private hospital 21% 35% 52%

Trends by level of careTrends by level of care

6567

54

3329

25

2023

-

10

20

30

40

50

60

70

80

1988 1993 1998 2008

Year

Ag

e-s

tan

da

rdis

ed

ra

te*

in

res

ide

nti

al

ag

ed

ca

re

Rest-home

Hospital

* per thousand aged 65+ years, standardised to Auckland region 2006 population

Trends in Mobility

(p=<0.0001, decreased mobility over time)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1988 1993 1998 2008

Bed/chair bound

Moves independently in wheelchair

With two person assist

With one person assist

With stick or walker

Without aids

Trends in Urinary continence

(p=<0.0001, increased urinary incontinence over time)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4

Persistently incontinent

Incontinent every 24 hours

Incontinent weekly or less

Continent if toileted regularly

Continent

Trends in Memory

(p=<0.0001, increased problems with memory over time)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4

Unable to assess

Loss of memory for recent & remote eventsLoss of memory for recent & remote eventsLoss of memory for recent eventsNo memory defect