Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage

The continued increase in hospital admission is a significant and complex issue facing health services in Australia and internationally [1, 2]. Frequent hospital admissions that are potentially avoidable stretch health services and budgets as well as patients and their carers/family [3]. Research exploring characteristics of patients with a history of frequent admission has identified healthcare utilisation patterns, individual characteristics and environmental factors as risk factors [2, 4‐7].

Prior hospital admission is a predictor of readmission and frequent admission [2, 8, 9]. Frequent admission is associated with older age, being male, having high levels of comorbidity and disease severity, depression, anxiety or psychosis [6, 7, 10, 11]. Environmentally, lack of social support [6, 10] and socio-economic deprivation [10, 12, 13] have been shown to impact on admission patterns, but little is known about how these factors influence admission patterns in rural areas.

Ambulatory Care Sensitive (ACS) chronic conditions are conditions such as diabetes, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) which respond well to care in primary healthcare settings and for which hospital admission may be avoided with quality primary care [14]. Frequent hospital admissions are associated with chronic ACS conditions [2]. Older patients with chronic conditions make the greatest contribution to ACS admissions [14‐17].

Hospital admission for ACS conditions is particularly burdensome in rural and remote Australia [14, 18‐20]. In the North Coast of NSW the rate of admission for ACS conditions from 2001–6 was higher than the NSW rate [21]. The 2006–7 rate of admission for ACS chronic conditions (excluding diabetes) in very remote regions of New South Wales (NSW) was almost double that in major NSW cities [22]. Previous research on ACS admissions has primarily explored urban populations, with little attention to potential differences for rural patients [2, 4, 6].

Australian research on avoidable admission has generally used ACS conditions as a proxy for avoidability, and has relied on analysis of routinely available hospital admissions data. Classifying a hospital admission for an ACS condition as ‘potentially avoidable’ does not imply that the individual admission is actually avoidable. Rather, it is a population measure based on specific admission diagnoses [23]. Further, the timescale of any notion of “avoidability” inherent in an ACS admission is unclear, i.e. was the admission avoidable with primary healthcare intervention on the day/month/year or decades before the admission? Therefore the use of ACS admissions as a proxy for avoidable admissions for planning interventions focused on individuals, presents difficulties. The proportion of ACS admissions that might actually be avoidable remains unknown and little research has explored the avoidability of specific admissions or the antecedents to admission from the perspective of patients [17, 24, 25].

The NSW Health Connecting Care Program launched in 2010 aimed to improve chronic disease management amongst patients with frequent hospital admissions for selected chronic conditions by improving coordination of their care. Patients eligible for inclusion in the North Coast Connecting Care Program were older patients resident in rural North Coast NSW with 3 or more hospital admissions for ACS chronic condition within a 12 month period.

Our study addressed gaps in current knowledge by investigating this rural patient group, and aiming to: report findings of a cross-sectional survey of this group of patients (describing their demographic, health, management of their condition and social characteristics, and exploring the avoidability of individual admissions, from the patient perspective); and determining factors associated with patients who are frequently admitted (3 admissions in 12 months) compared with those who are very frequently admitted (4+ admissions in 12 months). In addition, we explored whether survey respondents were representative of patients targeted by the Connecting Care Program, by linking patient survey data to hospitalisation and Connecting Care Program data to compare characteristics of the patient group as a whole with the subset of patients who participated in the survey. The results of our study will inform the design of interventions to better manage patients with frequent admissions for chronic disease and potentially reduce hospital admissions within this patient group. Our study obtained ethical approval from the North Coast Area Health Service Human Research Ethics Committee.

Our survey targeted patients eligible for inclusion in the North Coast Connecting Care Program, i.e. residents of North Coast NSW with three or more unplanned hospital admissions for selected ACS chronic conditions in any 12 month period from July 2008 to December 2009. The full eligibility criteria are summarised in Table 1. The North Coast of NSW is a 500 kilometre-long coastal strip along the NSW north coast, and shares a state border with Queensland. The population is around half a million, and is mostly concentrated in regional cities and towns with the remaining population scattered across the rural hinterland.

Patients were identified as being eligible for the North Coast Connecting Care Program by NSW Health in the first quarter of 2010. Patients were sourced from routinely collected admissions data from North Coast NSW hospitals in the public sector. In October 2010 a letter (including an information sheet and consent form) inviting patients to participate in the research was mailed to all eligible patients, excluding those who were known to have died (101 patients) or moved to an aged care facility (96 patients). Patients who did not respond received a second invitation 2–3 weeks later. Patients who granted consent were mailed the survey questionnaire (and a stamped addressed return envelope) and asked to return the completed survey by post.

Patients who consented to participate in the survey but did not return a completed questionnaire were mailed the survey again. Consenting patients who still had not responded were telephoned to ask for return of the completed questionnaire, and a number of participants were sent the questionnaire again at this point. Figure 1 summarises recruitment for the survey.

Our survey results describe an elderly rural group of patients with multiple hospital admissions for chronic disease. This group had high rates of comorbidity and a large proportion entered aged care or died within the study period. The group were predominantly of lower socio-economic status, and social isolation and psychological distress were common. Factors significantly associated with more frequent admission (4+ admissions compared to 3 admissions) were a diagnosis of CHF, a lower social network score i.e. respondents with smaller social networks and with less social contact, and a higher Charlson Comorbidity Index score. All patients in the invited group had a GP and our results suggest that at least from the patients’ perspectives their hospital admissions were appropriate and unavoidable on the day. Fewer than half our respondents had a written GP care plan.

Significantly fewer of our survey respondents rated their general health as good or better compared to the North Coast population aged 75 and over [39] (32% vs 72% p<0.001). Generally, respondents were of low socio-economic status which is consistent with the literature [16, 40]. Most respondents were on a pension (81%) and this rate is significantly higher (p=0.001) than for the 65+ population in the North Coast Area Health Service area in 2009 (69%) [39]. Nearly one quarter (22%) of respondents reported difficulty affording their medication with important implications for the treatment of their condition and for avoiding hospital admission.

We anticipated that medication would be an important factor in frequent hospitalisation for this group based on the literature [41‐43] and previous work by our group [26]. One third (34%) of the invited group (n=512) were using five or more medications (defined as ‘polypharmacy’ by Linjakumpu et al. [44]), the complexity of which may lead to interactions and/or medicine mismanagement. Nearly a quarter of men reported ever having forgotten to take their medication. Interestingly, men with a Webster pack reported forgetting more than men without a Webster pack (34.8% vs 16.2%). This may be because those who were having difficulty remembering their medications were more likely to be offered these packs. Interventions such as the Home Medicines Review (HMR), conducted in the community in Australia, have been shown to be effective at reducing potentially inappropriate medicines in older age groups [45], which might lead to hospitalisation. Greater access to HMR in rural areas via GPs (particularly given this patient group appear to have GPs) might make a contribution to improving individual medication management, although access to pharmacists in rural areas can be problematic, and increased access to HMRs does not address the issue of affordable medication. We had no evidence of the utilisation rates of HMR in our respondents.

Social isolation was an important factor for many of our respondents. We were not able to explore social isolation in non-respondents as it is not routinely collected in hospital admission data. One third (34%) of respondents lived alone (more commonly women). This is significantly higher (p=0.018) than in the general population where 25% of older people (60+) in NSW live alone [46]. The social network scores amongst our respondents indicated greater social isolation than in a recent study of Australian women 70–85 years who had experienced a major illness in the last 12 months, or who had a probable psychiatric condition [47]. One quarter (25%) of respondents spent no time with friends/family they didn’t live with in the previous week. Of the 35 respondents who lived alone, six of these (all men), had no social contact with friends/family nor attended meetings or clubs (their median Dukes network score was 6) in the previous week. Consistent with other studies [47], the least socially isolated respondents were women living alone. Previous work has shown social isolation associated with poor health, depression and loss of confidence [48]. A recent qualitative study reported that fifty six out of one hundred elderly people interviewed who presented to an Australian city public hospital emergency department reported feeling socially disconnected [49]. Our own qualitative study with a broad range of community-based health and support service providers suggested that social isolation was a key factor contributing to frequent and/or avoidable hospital admissions amongst older patients with chronic disease [26]. This is supported by the finding that among survey respondents, greater social isolation was associated with having more frequent admissions (4+ admissions). The possible complex mechanisms whereby social isolation might contribute to admission in older rural patients with chronic disease, for example social isolation leading to depression leading to lack of motivation for self-management, are discussed in our paper on this topic [50].

A number of related social factors were identified which may be contributing to the high use of hospital services. Nearly one third of respondents reported having no car they could drive and of those living alone, 29% had no car access. This has implications not only for exacerbating their social isolation but also for accessing services in rural Australia where public transport is limited or non-existent, if they have no friends or family to take them. One in five (22%) of respondents who reported needing regular help with daily tasks e.g. personal care, did not have either a close friend or relative who regularly cared for them. While these patients may have obtained carer support from community or social services, a degree of unmet need is likely to be present.

There are a number of community based services which might partially ameliorate the impact of social isolation including valuable community transport initiatives, however, many of these services have been reduced in recent years e.g. services which used to offer accompanied shopping trips now only offer unaccompanied shopping [51]. These services often have long waiting lists and there are often considerable additional barriers to accessing services, sometimes specific to rural locations [51, 52]. Increasing this provision and access to it, may present an opportunity to impact on social isolation which may in turn affect hospital admission amongst this patient group.

Over half the respondents (53%) had mild, moderate or severe psychological distress (scoring over 15 on the K10 assessment). With 60% of those aged 65–74 years and 46% of those 75 or older experiencing psychological distress. This is significantly higher than for the corresponding age groups in the general Australian population (25%, p<0.001; and 29%, p<0.001, respectively) [53]. This finding points to possibly undiagnosed psychological distress amongst this group. Psychological distress may contribute to hospitalisation through poor chronic disease management due to low incentive and energy to self-manage [54, 55]. This suggests that improved GP attention to the mental health status of patients with chronic disease and a history of frequent admission might be beneficial in both diagnosing and treating mental health disorders, as well as activating self-management [56]. However, the majority of survey respondents rated their self-management as reasonably good.

While all the study population were registered with a GP, we had no information on the nature or frequency of contact with their GP. Only one in three (34%) survey respondents recalled receiving regular reminders to visit the GP, and only 38% reported having a written care plan. Our study population is composed of the type of patient for whom care plans are thought to be particularly beneficial. This suggests a failure of delivery of best practice in primary care amongst this group which could possibly be improved and warrants further exploration.

In our study population COPD and coronary artery disease were the most common primary diagnoses. A higher Charlson Comorbidity Index score was associated with more frequent admission, as was congestive heart failure. Given that congestive heart failure is characterised by progressive deterioration, frequent hospitalisation and requires complex self-management, this is not surprising [41]. An ethnographic study of self-management by people with diabetes has described the difficult balancing act required, and that capacity to self-manage was limited for some people by their co-morbidity, psychological factors and social capital, all issues among our population [57]. While the specifics of self-management for diabetes are different to those for heart failure, they are similarly complex, require close self-monitoring, careful attention to diet and medications, and impose important social restrictions. In North Coast NSW there is a well-established and regarded Heart Failure Program, and evidence exists demonstrating that programs for CHF can reduce hospitalisation in the short term amongst specific groups [58]. However, difficulties with these kinds of programs relate to access, particularly in rural areas, and ‘maintenance’, a crucial factor with all chronic disease but particularly with CHF. Programs run for a finite timeframe of a few weeks of contact per patient, whereas many patients require longer-term regular on-going support to sustain their motivation and capacity for modifying health behaviours (for example monitoring fluid intake), and/or to account for the fact that these patients often have poor short-term memory and some dementia [51].

The high mortality amongst this group represents a significant study challenge. In our study nearly one in five (n= 136, 19%) patients of the initially identified 709 were known to have died within 2 and one half years (between July 2008 and January 2011). Since the commencement of the Connecting Care Program (and the identification of our study population) the eligibility criteria for the Program has been amended to identify patients at the hospital when they are admitted rather than retrospectively (as was the case in this cohort), to include patients of all ages and to lower the threshold of multiple admissions from the 3 plus used initially [59]. This will likely target patients less ill than those in the study population we report in this paper, and may extend the scope for improving disease management and thus reduce future potentially avoidable admissions.

This study provides a detailed description of older patients dealing with multiple chronic conditions and a history of frequent admission in rural Australia. While the disease severity amongst this group likely limits opportunities to reduce hospital admissions through improved community-based care, some situations were identified in which admission might have been avoided through greater medication adherence and modified health behaviours. This study also identified a number of areas of potentially unmet need amongst this highly vulnerable population including difficulty affording medication, difficulty in accessing services in rural areas, poor medication management, social isolation and mental health issues. Greater GP input into care planning, education and behaviour modification may help. Addressing these areas may have the potential to impact on frequent hospital admission amongst this patient group.

This project was initiated by the concerns of staff in our local general practice network and public health service. Two of our investigators on the project have joint appointments between the Local Health District and the University Centre for Rural Health.