Outcomes After Unplanned Admission to Hospital in Older People: Ill-Defined Conditions as Potential Indicators of the Frailty Trajectory

Objectives: To describe outcomes after unplanned hospital admission in older people and to determine whether disease trajectories in those admitted with ill-defined conditions (symptoms and signs) are distinct from other diagnostic groups and consistent with known disease trajectories.Design: Longitudinal follow-up after a retrospective cross-sectional study of emergency admissions to general internal and geriatric medicine units in one hospital.Setting: Acute hospital in southern England.Participants: All people aged 65 and older with unplanned admissions to general internal and geriatric medicine inpatient units during 2002 (N = 5,312).Measurements: Age, sex, comorbidity, presence of cognitive and mood disorders, residence, and primary diagnostic group at discharge. Outcomes were death up to 36 months from admission, any readmission, and readmission for ill-defined conditions up to 36 months after discharge.Results: There were significant differences in death rates between the diagnostic groups, with mortality being highest in individuals with a primary diagnosis of cancer and lowest in the ill-defined conditions group. Nearly 83% of the ill-defined conditions group survived the follow-up period. Adjusted Cox proportional hazard models indicated that, when age, sex, comorbidity, residence, and cognitive and mood disorders were accounted for, the ill-defined condition group had a lower risk of death but a higher risk of subsequent readmissions for ill-defined conditions than any other group. Overall readmission risk was highest for individuals admitted for a respiratory condition but was similar in all other diagnostic groups.Conclusion: The lower mortality risk associated with ill-defined conditions is consistent with chronic rather than acute needs, but the pattern of mortality and readmission is more consistent with the frailty than the chronic organ system failure illness trajectory, suggesting that functional support needs may be more important in this group of individuals

Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: retrospective analysis of hospital admissions data in England

BackgroundRising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes.MethodsRetrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay.ResultsIncidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05).ConclusionsR-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.<br/