Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial

An increasing demand among elderly for hospital beds and other health services make allocation of resources to the most efficient care level a vital issue [1]. In 1995 there were 42.8 admissions to general and university hospitals per 100 persons above 80 years in Norway. This increased by more than 40% to 60.8 in 2005 [2].

Both in UK and Norway there is a particular challenge of Payment by Results where tariffs in general and university hospitals are set on a diagnosis and procedure-based system, which does not account for increased lengths of stay for patients with physical disability [3, 4]. In the UK the number of persons with physical disability and a high level of need of care are estimated to increase by 54% by 2025, most of these will be older persons [5]. In addition to the loss of health and function for the patients and the social and economic burden for their families, this increased need of care is considered to be a major economic challenge for societies worldwide [1].

Moreover, fragile elderly patients often have to stay at general hospitals after the treatment of the acute illness is completed due to lack of a stable social network, lack of familial or municipal capacity to deliver proper care in their own homes or shortage of suitable nursing home beds [6].

The health care provision in Norway is based on a decentralised model [7]. The municipalities (primary health care) are responsible for home care services, nursing homes, community hospitals, family physicians, health cervices for mothers, children and youth, midwives, physiotherapists, occupational therapists and emergency services. The government (secondary health care) owns and runs district general hospitals, university hospitals and ambulance services through regional health authorities (five regions).

In 2001 an intermediate care department was established at a teaching nursing home (community hospital) [8] located in the city of Trondheim, Norway to perform intermediate care [9] for older patients initially admitted at the city general hospital, but without any need for further advanced hospital care. The goal was to create a department functioning as a new link between advanced care at a general hospital and community home care to optimise recovery before returning home after general hospital care [7]. There is little published knowledge about patient outcome and cost effectiveness when intermediate care [9] is provided at a community hospital instead of standard care at a general hospital [10‐14].

From August 2003 until the end of May 2004 142 patients were eligible for inclusion and 70 were randomised to continued care at the general hospital (general hospital group) and 72 to the community hospital (intervention group) (Figure 1). All patients randomised for care at the community hospital were transferred from the general hospital within 24 hours after the time of inclusion to the study and immediately after the time of randomisation. Sixty-four patients were transferred from the general hospital to intermediate care (intermediate care group), as eight of the patients randomised for intervention were never transferred due to an acute and severe deterioration of their medical conditions after inclusion. In the intention-to-treat analyses they were included in the intervention group, otherwise, in the treatment-analyses they were dealt with as a separate group. There were no dropouts, except for deaths, during the trial and for all patients all data were collected from the first day at the general hospital and until the end of the trial or at the time of death.

This trial demonstrated that elderly patients with acute diseases or deterioration of a chronic disease initially handled at a general hospital and subsequently offered intermediate care, had lower readmission rates (p = 0.03), and had a higher number of patients independent of community care (p = 0.02) than patients given traditional prolonged care at a general hospital. The differences in total number of days with inward care were minor. The differences in number of deaths and need of home care were in favour of the intervention group, however, statistically insignificant.

All patients were transferred immediately after randomisation to the community hospital except the eight patients with a severe and acute deterioration of their disease. These patients could have been treated as readmissions for the same diseases in the intention-to-treat analyses. However, the decisions not to transfer these patients were undertaken by the physicians at the general hospital and not by the physicians at the community hospital. Treated as readmissions in the statistical analyses resulted in an insignificant reduction of the number of readmissions (p = 0.14, adjusted p = 0.11) and an insignificant difference in number of days readmitted in favour of the intervention group; 4.4 (95% CI 2.6–6.9) days versus 7.6 (95% CI 3.6–11.6) days.

The present study appears to be the first randomised controlled trial where included patients have been an unselected general hospital population above 60 years of age. Another strength of this trial was that all patients received the same optimal care in the initial stage of their illness before randomisation.

As one of the authors, blinded for which group the patients belonged to, collected all information from medical records and from the patient administrative systems, information bias by collection was possible. As all data was objective measures as readmissions for the same disease, use of home care and number of deaths, the registration was considered to be accurate.

Several efforts have been developed to reduce number of days of inward care and to facilitate discharge from general hospitals including discharge planning, nurse led inpatient care, hospital at home regimes, general practitioners hospitals, community hospitals and patients hotels [10]. Some studies have found a better functional outcome and reduced mortality when older patients were treated at specialised geriatric wards [17‐19], whilst the benefit of early supported discharge of stroke patients was ascribed a structured collaboration between primary and secondary health care [20, 21].

Several community hospitals in Norway are comparable with community hospitals in England [7, 8] and general practitioners hospitals in Holland [23] where some studies have explored their appropriateness [11, 12, 22‐25]. In Norway the use of nursing homes and community hospitals may have been overlooked as appropriate alternatives, and research on such models has been sparse both nationally and internationally [7, 22].

A limitation of performing intermediate care is the lack of possibility to identify which of the components that are working so well. However, some of the main components in the intervention were assessments of ADL and a consecutive and closely communicating and cooperating with each patient and his social and professional networks to identify the best supportive solutions. This communication, including the continuous dialogue with the rest of the primary health care in the municipality, was probably the central element of the care that seems to be efficient in reducing the number of readmissions for the same disease, the need of community care and allowing the professional teams to optimise the follow-up after discharge.

The communication process is always complex. Older people are a more heterogeneous group than younger people, and maybe they have experienced several more or less successful diagnosing and treatment procedures. Health personal and older people can have different perception of what are illness and the consequences of illness. As a consequence, unclear communication can cause the whole medical encounter to fall apart.

Intermediate care at a community hospital seems to be highly effective.

In a modern health care system care is more and more specialised, fragmented and organ-focused. In addition to the expansion of further sub-specialising in modern medicine, the results from this study underscore the additional need of better step-down care systems at an intermediate level. It is indeed relevant to question the appropriateness of prolonged traditional general hospital care for this rapidly increasing group of patients.

There are little existing scientific evidence of the benefits of intermediate care [26] and more randomised controlled trials are necessary to test different models for intermediate care at community hospitals as alternatives to general hospital admissions and as alternatives to prolonged general hospital care to confirm any benefits of intermediate care. Additionally, the economic consequences have to be explored.

Intermediate care at a community hospital compared to ordinary prolonged care at a general hospital, reduced significantly the number of readmissions for the same disease to the general hospital and increased significantly the number of patients being independent of community care after 26 weeks of follow-up, with an insignificant increase in the number of days in institutions and without any increase in mortality. Regarding morbidity and mortality after 26 weeks of follow-up, the results favors alternative intermediate care at primary level.