Hospital transfer of people with dementia: results of the European RightTimePlaceCare project on their frequency, factors associated and costs

doi:10.21203/rs.3.rs-22961/v1

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Research article

Hospital transfer of people with dementia: results of the European RightTimePlaceCare project on their frequency, factors associated and costs

https://doi.org/10.21203/rs.3.rs-22961/v1

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published 05 Nov, 2020

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Background

Hospitalisation is a critical moment for people with dementia and a major challenge for health care systems. The aims of this study were 1) to describe the frequency of hospital transfer among people with dementia from eight European countries, 2) to examine the factors associated with hospital transfer and 3) to evaluate the costs related with it.

Methods

The present study is a secondary data analysis of the RightTimePlaceCare European project. A cross-sectional survey was carried out with data collected from people with dementia who lived either at home or had been admitted to a nursing home in the last three months, as well as from their caregivers. Data on hospital transfers at three months were gathered with the "The Resource Utilization in Dementia" instrument. Demographic data, functional, cognitive and neuropsychiatric symptoms, comorbidity, polypharmacy, caregiver burden, nutritional status and falls were evaluated with validated tools. Multivariate regression models were used to investigate the factors associated with hospital transfers. Costs were estimated by multiplying quantities of resources used with the unit cost of each resource and inflated to the year 2018.

Results

The study sample comprised 1,700 people with dementia and their informal caregivers. Within three months, 16.7% experienced ≥ 1 hospital transfers. Multivariate logistic regression model showed a higher probability of hospital transfers among people with dementia with unintentional weight loss, polypharmacy, falls and those living in the community. The estimated costs per person with dementia/year among the participants living in a nursing home were 980.56 euros and 2,535.39 euros among those receiving home care.

Conclusion

Transfer to hospital is frequent among people with dementia, especially among those living in the community. These events are associated with the onset of geriatric syndromes such as involuntary weight loss, accidental falls and polypharmacy, and impose a remarkable economic burden. These results suggest that there is a need to develop and implement cost-effective supportive interventions that focus on the identification of people with dementia at risk of hospital transfer, the assessment and management of these geriatric syndromes and the promotion of individualised care planning for them, in order to prevent unnecessary hospital transfers.

Geriatrics & Gerontology

Aged

Dementia

Geriatric syndrome

Home care

Hospitalisation

Nursing home

Dementia is a major cause of disability and dependency among older people worldwide and has a physical, psychological, social and economic impact on the persons affected, their families and caregivers, and the society. According to the World Health Organization (WHO), the number of people living with dementia worldwide is estimated to be at 47 million, rising to 75 million in 2030 and 132 million in 2050 (1).

People with dementia have increasing needs for care and supervision through the trajectory of the disease and, in advanced stages, the difficulties for these people to be cared for at home increase, with many of them needing to receive care in nursing homes (NH) (2). People with dementia represent a high percentage of the people living in nursing homes. Seitz et al. reported a prevalence of 58% worldwide over a 20-year period (3).

Studies carried out in community settings has shown that people with dementia are significantly more likely to be hospitalized (4,5) with a percentage between 60 and 70% (6), to have longer lengths of hospital stay (7), and higher health care costs (8) than people without cognitive disorders.

In the nursing home setting, research has shown that older adults living in these facilities, including those with dementia, are frequently transferred to hospital Emergency Departments (ED) for acute health crisis management. Up to 78% of the referred residents may experience an in-hospital stay (9). Reasons for hospital admission include infections, falls, coronary and gastrointestinal disease or feeding tube-related complications (10,11).

Thus, transfer to ED and hospitalisation appear to be common events for people with dementia both in the community and in nursing homes. However, there is a lack of studies that provide data on the frequency of ED transfers and hospitalisation among people with dementia both in the community and nursing home settings.

Despite the benefits of receiving specialized care, multiple negative health outcomes have been associated with the admission to hospital of frail older people, including fall-related injuries, nosocomial infections, pressure ulcers, delirium, functional decline and an elevated risk of mortality (12–14). The identification of factors associated with hospitalisation may help preventing unnecessary adverse events (15,16). However, only few studies have investigated which factors may be associated with hospital admissions among people with dementia. Higher comorbidity, older age, male sex, previous acute hospitalisation and shorter duration of dementia symptoms have been identified as factors associated with hospitalisation among people with dementia living in the community (6,17). These factors are less known among older people with dementia who live in nursing homes (16). In addition, there is a lack of studies comparing hospital or ED use of people with dementia living the community with those living in nursing homes (18).

Healthcare costs, including inpatient care, outpatient care and pharmaceutical costs represent a significant burden on the total costs of dementia care. Several reviews of cost-of-illness (COI) studies of dementia have been conducted in previous years (19–23) highlighting the heterogeneities and important limitations existing because of methodological differences(24). Although there is still no consensus on how to carry out these studies, different aspects such as disease severity, care setting and cost perspective, have been identified as main factors to be considered for future research (21,22,25).

Analysis of the costs associated with the hospital admission of people with dementia living in the community and in NH is a research area of interest, as the optimisation of resources or their refocusing towards targeted interventions in the area of home care or in nursing homes can lead to the prevention of unnecessary and costly events of hospital transfer (26).

Aim

The aims of the present study are: 1) to describe the frequency of hospital transfer (including emergency department and hospital admissions), among people with dementia from eight European countries living in the community or in nursing homes settings; 2) to examine the factors associated with hospital transfer; 3) to evaluate the costs associated with hospital transfer.

Design

This study is a secondary analysis of a large European research project called 'RightTimePlaceCare' (RTPC). The RTPC survey was a longitudinal prospective study, conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Spain, Sweden, and the United Kingdom). The project aimed to improve health and social care services for European citizens with dementia and focused on the transition from professional home care towards institutional nursing care. Further details are published elsewhere (27).

Participants

The RTPC survey comprised two groups of participants: 1) People with dementia newly admitted to NH (i.e. within one to three months after admission) and their informal caregivers; 2) People with dementia who received professional home care and were at risk of institutionalization (as judged by a professional responsible for their care) along with their informal caregivers.

Inclusion criteria for people with dementia were if they (1) had a primary diagnosis of dementia as diagnosed by an expert (e.g. physician, psychiatrist, neurologist, geriatrician, or general practitioner, depending on countries’ diagnostic procedures); (2) scored 24 points or lower on the Standardized Mini Mental State Examination (S-MMSE) (28); and (3) had an informal caregiver who visited the people with dementia at least twice a month. People with dementia were excluded when they (1) were younger than 65 years; (2) had a primary psychiatric diagnosis or Korsakoff syndrome; and, for the group recently admitted to NH, (3) were only temporarily resident in the NH (e.g. rehabilitation, respite of the informal caregiver) with the intention of moving back home.

Procedures

Each country obtained ethical approval from a country specific legal authority for research on human beings (for example an ethical committee specialized in medical or nursing science) to conduct the study in accordance with their national standards and regulations. Country-specific consent procedures were followed.

Data were collected by trained interviewers at baseline between November 2010 and April 2012 and follow-up interviews were conducted after 3 months (27). All interviewers were professionals in health or social care or medical/nursing/social care students with practical experience and at least a Bachelor’s degree. The interviews were conducted with informal caregivers as informants (usually spouses/partners or children), formal caregivers and the people with dementia (to assess cognitive impairment).

Measures

Sample characteristics

At baseline, information on the age, sex, country and living situation (i.e. home care (HC) vs nursing home (NH)) of the people with dementia was collected. Cognitive status was assessed with the S-MMSE (range 0–30), with higher scores indicating less cognitive impairment (28). The disease severity was defined as mild (S-MMSE > 21), moderate (10–21), or severe (< 10) (29). Missing values were considered when no valid S-MMSE value was available and were included in the severe dementia group. Medical history of past and current clinical conditions were recorded based on the Charlson Comorbidity Index (CCI) (range 0–37), with higher scores indicating more clinical conditions and a score > 2 indicating moderate comorbidity (30). Independence in activities of daily living (ADL) was measured by the Katz index (range 0–6); we categorised dependency as mild (Katz index 5–6), moderate (2–4), or severe (< 2) (31). Behavioural and psychiatric symptoms in dementia were evaluated with the Neuropsychiatric Inventory Questionnaire (NPI-Q). The NPI-Q comprises 12 domains: agitation and aggression, delusions, hallucinations, depression, euphoria, aberrant motor behavior, apathy, irritability, disinhibition, anxiety, sleep, and eating, with 2 scores reported for each domain: (1) presence of symptoms and (2) severity on a 0–3 scale (0 = none, 1 = mild, 2 = moderate, 3 = severe; range 0–36), with higher scores indicating more (severe) symptoms (32). Presence of depressive symptoms was assessed using the Cornell Scale for Depression in Dementia (CSDD) (33). A higher score (range 0–38) indicates greater depressive symptomatology.

Furthermore, several quality of care indicators based on recent literature (34) were assessed at baseline: nutritional status (one item question ‘did the patient experience a weight loss of 4% or more of his/her weight in the past year?’) (35), polypharmacy (≥ 5 drugs) (36) and the occurrence of falls during the preceding three months.

Finally, caregiver burden was measured using the Zarit Burden Interview (ZBI) (37) which consists of 22 self-reported items. Total scores range from 0–88, with a higher score indicating higher perceived burden; three severity groups were defined: little or no burden (ZBI < 21), mild burden (ZBI ≥ 21–40), or moderate to severe burden (ZBI > 40) (38).

Information on hospital transfer

The Resource Utilization in Dementia (RUD) instrument was used to determine the health care resources used for people with dementia (39). The RUD instrument captures medical care resources use (e.g. medication, inpatient and outpatient care), community care services (e.g. home care, transportation, meals on wheels, day care), special accommodation (e.g. nursing home) and time spent with caring activities by informal caregivers. Information on hospital transfer since the baseline interview was gathered using an adapted version of the RUD instrument in the follow-up assessment that included the two concepts Hospital Admission (HA) and Emergency Department Admissions (EDA). With regard to HA, caregivers were asked: “since the last visit, was the person with dementia admitted to a hospital (for more than 24 hours)?”; “how many times was your relative/the resident hospitalised?”; “for each hospitalisation, please provide the diagnosis or reasons for hospitalisation”; “for each hospitalisation, please specify the total number of nights spent in each type of ward”. The following types of ward were asked about: geriatric ward, surgery ward, internal medicine ward, psychiatry ward and other hospital stays. With regard to EDA, caregivers were asked: “Since the last visit, did the person with dementia receive care in an accident and emergency hospital department (for less than 24 hours)?”; and if yes, “how many times”? Participants with at least one episode of HA or EDA were considered to have experienced a hospital transfer.

Estimate of cost for hospital transfer

While the costs of dementia were previously measured from a societal perspective in the RTPC project (40–42), our study focused on the assessment of direct medical costs generated by EDA and HA and calculated as average costs per capita and year in Euros (€). In the absence of valid and comparable unit costs for all participating countries, a common price vector based mainly on Swedish sources was used for all countries (40,43). For HA, the length of stay in each medical department was taken into account in the measurement. In the case of fees not being available for daily stay in departments other than internal medicine, geriatrics or surgery it was decided to assume a cost per day similar to the daily expense in the department of geriatrics. In addition, we calculated the average costs per capita and year specifically among those people with dementia who had suffered ≥ 1 hospital transfer. All costs were inflated to the year 2018 and currency conversion adjustments based on 2018 exchange rates were made for the non-EURO countries. Cost components, unit costs, the international adjustment schemes and their sources are shown in Table 1 (43,44).

Table 1. Unit costs and international price adjustments (inflated to the year 2018)

	Estonia	Finland	France	Germany	Netherlands	Spain	Sweden	UK
International price adjustment
Exchange rates; local currency / Euro	1.00	1.00	1.00	1.00	1.00	1.00	10.25	0.88
Medical Care (Inpatient care)
Costs* per day hospital (geriatric)	92.63	330.09	332.12	302.51	285.28	167.61	353.10	262.07
Costs per day hospital (internal medicine)	101.81	362.80	365.04	332.49	313.54	185.09	388.09	288.03
Costs per day hospital (surgery)	149.67	533.30	536.59	488.75	460.90	272.07	570.47	423.39
Costs Emergency room visit	63.39	226.01	227.39	207.11	195.32	115.30	241.76	179.42
Organisation for Economic Co-operation and Development (OECD). Prices, purchasing power parities (PPP) and Exchange rates (45)
*Costs are expressed in Euros

Statistical Analyses

The characteristics of people with dementia and their informal caregivers as well as the HA and EDA episodes are described using means and standard deviations (SD) for continuous variables and percentages for discrete variables. The assessment of the hospital transfer rates was made taking into account the estimated annual ED transfers and HA episodes, respectively, in addition to the total number of people with dementia participating in the study.

Univariate analyses were used to evaluate the independent variables (CCI, S-MMSE, Katz Index, NPI-Q scores, ZBI, CSDD, weight loss, polypharmacy, falls and setting) potentially associated with the occurrence of a Hospital Transfer (at least one episode of HA or EDA) using Mann-Whitney’s U test for continuous variables, Fisher’s exact test for dichotomous variables and Chi-squared tests for categorical variables with more than two categories. Statistically significant factors from these analyses were included in a logistic regression model.

All analyses considered a significance level α of 0.05 (two-sided) and were conducted with IBM SPSS Statistics version 25 (IBM Corporation, Chicago, IL).

Sample characteristics

The total RTPC sample at baseline comprised 2,014 dyads of people with dementia and their informal caregivers. For the present study, only participants with data available on EDA and HA were included. Thus, the study sample comprised 1,700 people with dementia and their informal caregivers (n = 1,054 (62%) from the HC setting and 646 (38%) from the NH setting).

The mean age of the study sample was 82.8 years (standard deviation (SD) 6.5), and 68.5% were women. The characteristics of the study participants are summarized in Table 2.

Table 2. Baseline characteristics of the study sample

Variables	Overall (n=1,700)
Setting
Nursing home, n (%)	646 (38%)
Home care, n (%)	1,054 (62%)
Age (years), mean (SD)	82.8 (6.5)
Women, n (%)	1,165 (68.5%)
Charlson Comorbidity Index (range 0-37)*, median (IQR)	2 (2)
S- MMSE (range 0-30)*, median (IQR)	14 (10)
Missing values	258
Katz Index (range 0-6)*, median (IQR)	3 (4)
Missing values	13
Severity of neuropsychiatric symptoms (range 0-36)*, median (IQR)	7 (9)
Zarit Burden Interview (range 0-88)*, median (IQR)	27 (22.3)
Missing values	6
Cornell Scale (range 0-38)*, median (IQR)	6 (7)
Missing values	149
Weight loss (≥4%, yes), n (%)	292 (17.7%)
Missing values	53
Polypharmacy (≥5 drugs, yes), n (%)	1,044 (61.4%)
Mean number of drugs (SD	5.5 (3.1) [5]
Falls in preceding 3 months (baseline)	387 (22.8%)
Missing values	4
Country, n (%)
United Kingdom	115 (6.8%)
Estonia	225 (13.2%)
Finland	268 (15.8%)
France	186 (10.9%)
Germany	190 (11.2%)
Netherlands	269 (15.8%)
Spain	240 (14.1%)
Sweden	207 (12.2%)
*Underlined scores are most favourable.
SD: Standard Deviation. IQR: Interquartile Range
Missing values declared when present.

Hospital transfer

Two-hundred and eighty-four of the people with dementia (16.7%) experienced at least one EDA (< 24 hours) or HA between the baseline and follow-up assessments. Out of the people with dementia experiencing at least one EDA and HA episode, the frequency of experiencing 2 or more episodes was 27.8% and 19.5%, respectively. We found an estimated HA rate per person with dementia/year of 0.45 and ED transfers rate per person with dementia/year of 0.55. Internal medicine was the department to which people with dementia were most frequently admitted and for a longer time period. Table 3 describes the frequencies of hospital transfer (EDA and HA) as well as, for HA, the frequencies of admission and the average length of stay in days in the different medical departments evaluated.

Table 3. Description of hospital transfer: Emergency Department Admissions (EDA) and Hospital Admission (HA)

	Overall (n=1,700)
PwD with at least 1 hospital transfer (EDA or 1 HA), n (%)*	284 (16.7%)
PwD with at least 1 EDA (with <24 hours stay), n (%)	171 (10.1%)
PwD with valid number of EDA**	158
PwD with 1 admission, n (%)	114 (72.2%)
PwD with 2 or more admissions, n (%)	44 (27.8%)
Total number of EDA episodes	236
PwD with at least 1 HA (with >24 hours stay), n (%)	193 (11.4%)
PwD with valid number of HA**	190
PwD with 1 admission, n (%)	153 (80.5%)
PwD with 2 or more admissions, n (%)	37 (19.5%)
Total number of HA	327
Department of HA, n (%)
Geriatric	55 (28.5%)
Internal Medicine	61 (31.6%)
Surgical	30 (15.5%)
Other	58 (30.1%)
Length of stay during HA admission in days, mean (SD) [Median]
Geriatric	11.8 (11.3) [8]
Internal Medicine	12.7 (11.7) [7.5]
Surgical	10.9 (13.2) [6]
Other	15.5 (23.3) [7]
Note: SD: Standard Deviation.
*: A PwD may have suffered both EDA and HA episodes.
**: Data on the number of EDA or HA available only for these participants.

Factors associated with hospital transfer

Table 4 (see Additional file 1: Table 4) contains the univariate analyses comparing the characteristics of people with dementia with and without at least one hospital transfer (HA or EDA). People with dementia with at least one hospital transfer compared to people who did not attend hospital were more frequently men, displayed more severe neuropsychiatric symptoms, presented more often polypharmacy, were more likely to suffer falls and weight loss, and had an informal caregiver who experienced a higher burden of care, especially in people living at home. By country, Germany and France recorded the highest percentage of referrals and Sweden the lowest.

The results of the multivariate logistic regression analysis are displayed in Table 5. The factors independently associated with hospital transfer were: a higher number of falls (OR 1.74, CI (1.28–2.37)), weight loss (OR 1.53, CI (1.08–2.15)), polypharmacy (OR 1.78, CI (1.28–2.48)) and living in the HC setting (OR 1.85, CI (1.33–2.58)). Furthermore, the analysis showed an approximately fourfold chance of hospital transfer in the United Kingdom, France and Germany compared to Sweden, the Netherlands or Estonia.

Table 5. Multivariate logistic regression analysis of factors associated with ≥ 1 hospital transfer

	Unadjusted OR [95%CI]	Adjusted OR [95%CI]
Setting, n (%)
Nursing home	Reference	Reference
Home care	1.42 [1.08-1.87]	1.85 [1.33-2.58]
Age (years)*
≤80 years	Reference	Reference
>80 years	1.18 [0.89-1.56]	1.20 [0.88-1.63]
Sex, n (%)
Female	Reference	Reference
Male	1.35 [1.03-1.76]	1.24 [0.92-1.67]
Charlson Comorbidity Index
≤2	Reference	Reference
>2	1.20 [0.91-1,56]	1.17 [0.85-1.59]
S-MMSE (sample range 0-24) score <10 or missing, n (%)
Mild dementia	Reference	Reference
Moderate dementia	0.95 [0.66-1.36]	1.00 [0.67-1.48]
Severe dementia	1.14 [0.79; 1.64]	1.14 [0.74-1.76]
Katz Index (ADL, sample range 0-6), mean (SD)
Severe	1.43 [0.94-2.17]	1.51 [0.92-2.49]
Moderate	1.07 [0.70-1.64]	1.18 [0.74-1.90]
Mild	Reference	Reference
NPI-Q Severity (behavior, sample range 0-30), mean (SD)	1.03 [1.01-1.05]	1.01 [0.98-1.03]
Zarit Burden Index sample range 0-88), mean (SD)
Little or no burden	Reference	Reference
Mild burden	1.11 [0.82-1.51]	0.91 [0.64-1.28]
Moderate to severe burden	1.56 [1.12-2.18]	1.09 [0.72-1.64]
Weight loss, n (%)
No	Reference	Reference
Yes	1.56 [1.14-2.13]	1.53 [1.08-2.15]
Polypharmacy (yes), n (%)
No	Reference	Reference
Yes	2.11 [1.58-2.82]	1.78 [1.28-2.48]
Falls in preceding 3 months
No	Reference	Reference
Yes	1.84 [1.39-2.43]	1.74 [1.28-2.37]
Country, n (%)
United Kingdom	3.27 [1.69-6.32]	4.08 [2.00-8.30]
Estonia	1.27 [0.66-2.46]	1.72 [0.84-3.53]
Finland	2.82 [1.58-5.03]	3.34 [1.80-6.21]
France	3.89 [2.14-7.05]	4.50 [2.36-8.58]
Germany	4.10 [2.27-7.40]	4.52 [2.41-8.50]
Netherlands	1.20 [0.63-2.27]	1.46 [0.75-2.86]
Spain	2.17 [1.19-3.96]	2.77 [1.45-5.32]
Sweden	Reference	Reference
CI: Confidence Interval
*Age and Charlson, Katz and S-MMSE indexes were added to the model for adjustment purposes, despite not being statistically significant in the univariate analysis

Costs of hospital transfer

Table 6 shows the estimated health cost per person with dementia/year according to country and setting (NH vs HC). Overall, the estimated medical cost per person with dementia/year related to hospital transfer was 1,944.55 €, with 100.61 € per person with dementia/year estimated for EDA and 1,843.95 € per person with dementia/year estimated for HA. In all countries, we found higher expenses per person with dementia/year in both ED and HA visits for people with dementia living in the HC setting compared to those living in the NH setting, except in the Netherlands, where a higher expenditure on hospitalisation of people with dementia living in NH was found, even if the global hospital transfer cost per person with dementia/year was lower with respect to the HC group.

Finally, the estimated annual medical costs generated by those people with dementia who suffered at least one EDA or HA were also evaluated according to the department of admission and country, with 270.62 € per person with dementia with EDA/year estimated, 4,103.02 € per person with dementia with HA/year estimated and 2,368.01 € per person with dementia with hospital transfer/year estimated. Table 7 shows the estimated annual medical cost of each person with dementia referred to the emergency department or hospital, according to the department of admission and country.

Table 6. Estimated average anual medical costs per person with dementia in the whole RTPC sample (n=1,700) ^{*, **,***}

Medical Care (Inpatient care)	Estonia n=225	Finland n=268	France n=186	Germany n=190	Netherlands n=269	Spain n=240	Sweden n=207	UK n=115	All countries n=1,700
Estimated n of people with dementia with EDA episodes (estimated EDA episodes/year)	48 (56)	124 (164)	56 (68)	84 (108)	72 (144)	136 (200)	36 (108)	76 (96)	632 (944)
Cost (NH)	6.34	65.16	129.94	125.52	52.59	54.26	12.56	130.49	66.47
Cost (HC)	20.98	190.02	72.28	109.24	137.32	119.02	178.53	167.46	121.53
Total cost of EDA	15.78	138.30	83.13	117.73	104.56	96.08	116.79	149.78	100.61
Estimated n of people with dementia with HA episodes (estimated HA days/year)	72 (816)	148 (2,656)	176 (1,832)	140 (1,072)	44 (204)	56 (1,012)	56 (1,308)	72 (1,000)	764 (9,900)
Cost (NH)	148.57	1,132.29	1,404.39	1,509.49	358.72	411.17	1,468.91	1,254.11	914.09
Cost (HC)	456.55	5,533.05	3,779.74	2,504.99	155.57	1,006.91	3,189.68	3,570.42	2,413.86
Total cost of HA	347.05	3,710.35	3,332.76	1,986.28	234.12	795.91	2,549.59	2,462.62	1,843.95
Estimated n of people with dementia with hospital transfer episodes	120	272	232	224	116	192	92	148	1,396
Cost (NH)	154.91	1,197.45	1,534.33	1,635.01	411.31	465.43	1,481.47	1,384.60	980.56
Cost (HC)	477.53	5,723.07	3,852.02	2,614.23	292.89	1,125.93	3,368.21	3,737.87	2,535.39
Total cost of hospital transfer	362.82	3,848.65	3,415.90	2,104.01	338.67	892.00	2,666.38	261.40	1,944.55
All expenses refer to costs per person with dementia, according to setting and country Costs calculated including only people with dementia with data available on the number of EDA or HA **All costs expressed in €. EDA: Emergency Department Admissions; HA: Hospital Admissions

Table 7. Estimated average anual medical costs per person with dementia who suffered EDA and/or HA by country^*,**

Medical Care (Inpatient care)	Estonia n=92	Finland n=216	France n=192	Germany n=204	Netherlands n=104	Spain n=156	Sweden n=68	UK n=104	All Countries n= 1,136
Estimated n of people with dementia with ≥1 EDA (cost)	48 (73.96)	124 (298.92)	56 (276.12)	84 (266.28)	72 (390.64)	136 (169.56)	36 (671.56)	76 (226.64)	632 (270.62)
Estimated n of people with dementia with ≥1 HA (cost)									764 (4,103.02)
Geriatric Department (cost)	4 (2,778.90)	8 (4,809.88)	144 (3,542.61)	24 (2,470.50)	0 (0)	8 (4,860.69)	0 (0)	8 (1,834.49)	216 (3,559.18)
Internal Medicine Department (cost)	24 (627.83)	52 (5,330.37)	0 (0)	52 (3,222.60)	4 (1,567.70)	20 (2,480.21)	28 (11,642.70)	44 (1,911.47)	224 (4,133.02)
Surgery Department (cost)	4 (748.35)	36 (6,755.13)	8 (3,756.13)	32 (3,115.78)	4 (2,765.40)	8 (5,441.40)	8 (11,979.87)	8 (4,445.60)	108 (5,203.04)
Other Departments (cost)	40 (1,222.72)	32 (10,604.14)	24 (3,321.20)	32 (1,588.18)	36 (1,267.91)	20 (2,949.94)	20 (5,296.50)	12 (12,404.65)	216 (4,065.75)
Estimated n of people with dementia with ≥1 hospital transfer (cost)	120 (680.29)	272 (3,792.05)	232 (2,738.61)	224(1,784.65)	116 (785.37)	192 (1,115.00)	92 (5,999.35)	148 (2,029.90)	1,396 (2,368.01)
Costs calculated including only people with dementia with data available on the number of EDA or HA; * All costs expressed in € EDA: Emergency Department Admissions; HA: Hospital Admissions.

In this cross-sectional study, 1,700 people with dementia from eight European countries participating in the RTPC study were investigated. Within a time period of three months, 1 out of 6 people living with dementia were transferred to the hospital at least once, with an estimated rate of hospital admission per person with dementia/year of 0.45 and an estimated rate of emergency department admission per person with dementia/year of 0.55. Four factors were identified as being associated with a higher probability of suffering at least one hospital transfer: living at home and receiving HC (versus living in NH), suffering weight loss, accidental falls and presenting polypharmacy.

A recently published systematic review on hospitalization rates among PwD people with dementia in the community found hospitalisation rates between 0.37 and 1.26 per person per year in high quality studies (i.e. with low risk of bias), and percentages of hospitalisation between 26% and 65% as reported in four studies with low risk of bias where participants were followed for one year (16). The estimated hospital transfer rate per person with dementia and year observed in our study is therefore within the previously published ranges.

People with dementia living at their homes had a higher risk of hospital transfer than those in the NH setting in the present study. This result could be explained because the people with dementia included in the HC subsample of the present study had to be identified as being at risk for nursing home admission and, therefore were likely to be a selected sample of persons with complex needs, while the people with dementia included in the NH setting had to be recently admitted to the NH. The caregivers of people with dementia who live at home may have had less support in managing health needs or higher levels of care burden (46), leading to a greater need for emergency service utilization and hospital transfer. Other reasons for lower hospital transfer needs in the nursing home setting compared with home care suggested in the literature are that, even if EDA rates at nursing home are high (13), some of these institutions may be equipped with specific care units for people with advanced dementia (47), have a wider availability to perform post-acute attention (48), receive specialized health support from geriatric (49) or end-of-life care more frequently, and they may have policies to prevent transferring those persons to hospital.

Sleeman et al. also found in a retrospective cohort study of 4,867 people with dementia, in their last year of life in England, that being in a nursing home was associated with a significantly lower number of ED visits (49). The authors argued that increasing bed capacity in NHs may have explained their results, as it may have played an important role in reducing pressure on emergency hospital care.

Conversely, other studies analyzing the impact of dementia on hospital and ED use among fee-for-service Medicare beneficiaries reported that people with dementia who lived in nursing homes were significantly more likely to visit the emergency department and be hospitalised than those who resided in their own homes (18). However, these studies included the general population of people with dementia living at home and thus their population was not comparable with the participants of the present study.

Our study evaluated geriatric syndromes as markers of vulnerability and complexity in people with dementia. Geriatric syndromes are known to predict an increased likelihood of hospitalization, affect quality of life (50), increase the use and cost of health care, and raise overall mortality among the general elderly population (51). In the present study, the presence of three geriatric syndromes (malnutrition, history of falls or polypharmacy) was associated with a higher risk of hospital transfer.

Unintentional weight loss has been found associated with increased morbidity and mortality among older adults (52), but the relationship between unintentional weight loss in people with dementia and the risk of hospitalization has been underreported. Conversely, falls are of great concern for people with dementia given their potentially higher number of visits to emergency departments and severe consequences, mainly hip fracture (53). Similarly, the concurrent use of multiple medications by an individual, has been found to be associated with several negative health outcomes including hospital admission (54,55).

Currently, evidence for effective interventions to reduce the risk of falls, to reduce polypharmacy and to improve nutrition is limited and requires further development (56–60). Nevertheless, the results of the present study suggest that the identification and management of these three geriatric syndromes might help preventing hospitalisation events among people with dementia. Furthermore, the promotion of an advanced and individualised care plan among people with dementia showing these geriatric syndromes may be particularly advisable.

In our study, a worse functional status according to the Katz Index was not found to be associated with a higher frequency of hospital transfer. In contrast, previous studies have documented a statistically significant association between an increased dependency on activities of daily living (ADL) and the risk of hospital admission (15,61,62). Furthermore, a lower MMSE and higher NPI scores were not associated with hospital transfer. Conversely, Albert et al. previously reported that advanced dementia was a significant risk factor for hospitalisation in contrast to people with mild or moderate dementia (7). Finally, higher comorbidity was not associated with a higher frequency of hospital transfer, consistent with previous reports (63), but with a different pattern than shown by Sheperd et al. in a recent meta-analysis, where multimorbidities were associated with hospitalisation with moderate confidence (16).

Although the comparison of hospital transfer between countries was not the aim of this study, the results showed some differences, with higher risk of hospital transfer among people with dementia living in United Kingdom, France and Germany. These differences may be explained by the different patterns of organization of health and social care or family support.

In the present study, we found an estimated expenditure per person/year attributable to hospital transfers of 1,944.55 €, with a higher estimated cost for people with dementia included in the HC group (2,535.39 €) compared to the NH group (980.56 €). Other costs related to health and social care (medications, informal and community care) have been evaluated in previous RTPC studies (40–42), highlighting that in most countries the main cost driver in the HC setting were the costs of informal care, followed by the community and medical care costs. In addition, it was noted that NH expenditure in each country was dominated by indirect (non-medical) costs generated by living in nursing homes (institutional care).

Contrary to our expectations and similar to other previous studies (21,64), the argument of rising medical costs resulting from living in NH was not confirmed in the RTPC sample. It was observed that medical costs associated with hospital admission (including EDA) were lower in the NH setting. Possible reasons for this have been argued before: this could be explained by the special characteristics of the participants in the HC setting of the RTPC study, on one side, but on the other side this could also indicate different diagnostic or therapeutic approaches in the NH group of people. These results may suggest that living in a nursing home may be more cost effective in terms of hospital transfer for those people with dementia with similar characteristics to the participants of the RTPC study, especially if we consider that the nursing home admission is generally not associated with a deleterious impact on their quality of life (65), health or emotional status (66).

Added to the cost calculation, we calculated the average estimated annual expenditures specifically for the group of people with dementia who suffered EDA and/or HA, which were 270.62 € and 4,103 € per person with dementia/year, respectively. It is important to emphasize that no broader direct costs related to medical care are shown since costs generated by the use of outpatient clinics, medication or rehabilitation were not included in our study. Even so, the medical costs of our study are in accordance with previously published European data (40,67,68). In this way, the estimated cost of hospitalisation of 2,368 € per person with dementia/year identified in our study is close to previous findings.

Our results suggest that the identification of people with dementia who are at particular risk of suffering a hospital transfer may be of special interest, as they are those with higher estimated average annual expenditures related with hospital transfer. The provision of interventions aimed at preventing these events and an adequate care planning may be particularly cost-effective for this group of people with dementia.

The findings of our study should be interpreted considering its limitations. First, the time period investigated for each participant was limited to three months, which may not represent the entire population of people with dementia requiring hospital admission over the one-year period, taking into account seasonal fluctuations; however, the prospective character of the study may have facilitated the acquisition of reliable data. Furthermore, the RTPC country samples may not be representative of the general national population of people with dementia. Next, although we accounted for multiple variables that may affect the need for hospital admission, there may also be additional unmeasured confounding factors that influence the use of hospital care, for example, specific health support at the community or nursing home setting in each country or even at the local level. Finally, several years have passed between data compilation and secondary analysis. However, the amount of published data on this topic is still scarce, and we do not expect that important structural and process changes in the health and social care systems have occurred within this time period.

To the best of our knowledge, this is the first study that evaluates internationally (across Europe) the frequency of hospital transfers among people with dementia living in nursing homes and home care settings, and analyses the associated factors and costs. Within three months, 17% of the people with dementia suffered at least one episode of hospital or emergency department admission. People with dementia living in the community were more often transferred to hospital and health care costs due to hospitalisation were higher, compared with those living in a nursing home. Also, people with dementia with unintentional weight loss, falls and polypharmacy were more frequently transferred to hospital, suggesting a need for supportive interventions that focus on the assessment and management of these geriatric syndromes and that promote individualised care planning for them. The analysis of the health costs associated with hospitalisation show a remarkable economic burden and supports the need to identify those people with dementia at special risk of hospital transfers.

CCI

Charlson Comorbidity Index

COI

Cost-of-illness

CSDD

Cornell Scale for Depression in Dementia

EDA

Emergency Department Admission

€

Euros

European Union

Hospital Admission

IEA

International Epidemiological Association

KATZ

Katz Index of Independence in Activities in Daily Living

Nursing Home

NPI-Q

Neuropsychiatric Inventory-Questionnaire

OECD

Organisation for Economic Co-operation and Development

Odds Ratio

PPP

Purchasing Power Parities

RTPC

RightTimePlaceCare

RUD

Resource Utilization in Dementia

Standard Deviation

S-MMSE

Standardized Mini-Mental State Examination

WHO

World Health Organization

ZBI

Zarit Burden Interview

Ethics approval and consent to participate

The Good Epidemiological Practice guidelines recommended by the International Epidemiological Association (IEA 2007) and the Helsinki declaration are followed. This study was approved by the Ethical Committee of the Hospital Clinic, Barcelona, Spain (2010/6031); the Ethics Review Committee on Human Research of the University of Tartu (196/T-3) and the Ethical Committee of the Hospital District of South-West Finland (8/2010), Finland; the Comité de Protection des Personnes Sud-Ouest et Outre-Mer, Toulouse, France (09 202 07); the Nursing Science Ethical Committee at the University of Witten/Herdecke, Germany; the Medical Ethical Committee of the Academic Hospital Maastricht/Maastricht University, the Netherlands (MEC 10-5-044); the Regional Ethical Review Board in Lund, Sweden (2010/538); and the National Research Ethics Service, North West 5 Research Ethics Committee, the United Kingdom (11/NW/0003) (Verbeek et al., 2012). Participants were informed of the study purpose, and they were free to participate or withdraw from the study at any time. They were asked to sign the informed consent form.

Consent for publication

No identifying information on any individual’s data is presented in this paper. All participants gave written informed consent.

Availability of data and materials

The datasets analysed during the current study are available from the RightTimePlaceCare (RTPC) consortium on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The RightTimePlaceCare study is supported by a grant from the European Commission within the 7th Framework Program (project 242153).

Authors' contributions

Anna Renom-Guiteras (ARG), F. Javier Afonso (JA) and Gabriele Meyer (GM) conceptualized the study and planned the statistical analyses. JA prepared the first draft of the manuscript, supported by ARG. All authors critically reviewed and approved the final manuscript.

Acknowledgements

We thank Robert Schmitz for his previous work analyzing transfer episodes among the participants of the RTPC study. We appreciate the collaboration of Georgina Ramírez Rodríguez, M.D. for her support at the cost estimations shown in the study.

Group authorship

The RightTimePlaceCare (RTPC) Consortium partners are as follows:

Coordinator

University of Witten/Herdecke (DE): Gabriele Meyer PhD, RN, professor (scientific coordinator, WP 1 leader), Astrid Stephan PhD, RN, Anna Renom-Guiteras PhD, Dirk Sauerland, professor (WP 4 and 6 leader), Dr Ansgar Wübker PhD, Patrick Bremer.

Consortium members

Maastricht University (NL): Jan P.H. Hamers PhD, RN; Basema Afram MSc, Hanneke C. Beerens PhD, RN; Michel H.C. Bleijlevens, PhD, PT; Hilde Verbeek, PhD; Sandra M.G. Zwakhalen, PhD, RN; Dirk Ruwaard, MD, Ton Ambergen, PhD.

Lund University (SE): Ingalill Rahm Hallberg PhD, RN; Ulla Melin Emilsson PhD; Staffan Karlsson, PhD, RN; Christina Bokberg, PhD, RN; Connie Lethin, PhD, RN.

University of Manchester (UK): David Challis, PhD, professor; Caroline Sutcliffe, MSc; David Jolley, PhD; Sue Tucker, MSc, RN; Ian Bowns, PhD; Brenda Roe, PhD; Alistair Burns, PhD, professor.

University of Turku (FI): Helena Leino-Kilpi, PhD, RN, professor; Jaana Koskenniemi, MNSc, RN, researcher; Riitta Suhonen, PhD, RN, professor; Matti Viitanen, MD, PhD, professor; Seija Arve, PhD, RN, adjunct professor; Minna Stolt, MNSc; Maija Hupli, PhD, RN.

University of Tartu (EE): Kai Saks, MD, PhD, professor; Ene-Margit Tiit, PhD, professor; Jelena Leibur, MD, MBA; Katrin Raamat, MA; Angelika Armolik, MA; Teija Tuula Marjatta Toivari, RN.

Fundació Privada Clinic per la Recerca Biomedica, Hospital Clinic of Barcelona (ES): Adelaida Zabalegui, PhD, RN, FEANS (WP 5 leader); Montserrat Navarro, PhD, RN; Esther Cabrera, PhD, RN (Tecnocampus Mataró); Ester Risco, PhD, RN; Carme Alvira, PhD, RN; Marta Farré, MSc, RN; Susana Miguel, MSc, RN.

Gerontôpole, University of Toulouse (FR): Maria Soto, MD; Agathe Milhet; Sandrine Sourdet, MD; Sophie Gillette; Bruno Vellas, PhD.

Authors' information

Affiliations

Geriatric and Palliative Care Department. Badalona Serveis Assistencials. Barcelona, Spain.

F. Javier Afonso Argilés

Universitat Autònoma de Barcelona, Barcelona, Spain

F. Javier Afonso Argilés & Anna Renom-Guiteras

Department of Nursing Science. Witten/Herdecke University, Witten, Germany

Gabriele Meyer & Astrid Stephan

Institute of Health and Nursing Sciences, Martin Luther University Halle-Wittenberg, Medical Faculty, Halle (Saale), Germany.

Gabriele Meyer & Astrid Stephan

Department of Epidemiology and Evaluation. Hospital del Mar, Parc de Salut Mar. Barcelona, Spain.

Mercè Comas Serrano

Member of the Health Services Research on Chronic Patients Network (REDISSEC), Spain.

Mercè Comas Serrano & Anna Renom-Guiteras

RWI – Leibniz-Institute for Economic Research, Leibniz Science Campus Ruhr and RUB, Essen, Germany

Ansgar Wübker

Department of Nursing Science and Nurse Director, University of Turku, Turku University Hospital, Turku, Finland

Helena Leino-Kilpi

Department of Health Sciences. Faculty of Medicine. Lund University. SE-221 00 Lund. Sweden

Connie Lethin

Clinical Memory Research Unit. Department of Clinical Sciences. Lund University. SE-221 00 Lund. Sweden

Connie Lethin

Department of Internal Medicine, University of Tartu, Tartu, Estonia

Kai Saks

Department of Geriatric Medicine, Gerontopole, Alzheimer Disease Research Center, Inserm UMR 1027, University Hospital of Toulouse, France

Maria Soto-Martin

School of Health Sciences. University of Manchester, Manchester, UK

Caroline Sutcliffe

Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands

Hilde Verbeek

Living Lab in Ageing and Long-Term Care, Maastricht, The Netherlands

Hilde Verbeek

Hospital Clinic de Barcelona, Barcelona, Spain

Adelaida Zabalegui

School of Medicine, Universitat de Barcelona, Barcelona, Spain

Adelaida Zabalegui

Geriatric Department. Parc de Salut Mar. Barcelona, Spain.

Anna Renom-Guiteras

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Additional file 1:

Table 4. Univariate analyses with the characteristics of people with dementia with or without ≥ 1 hospital transfer

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Additionalfile1.xls

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Editorial decision: Major revision
06 Jul, 2020
Review #2 received at journal
05 Jul, 2020
Review #1 received at journal
29 Jun, 2020
Reviewer #2 agreed at journal
26 Jun, 2020
Reviewer #1 agreed at journal
22 Jun, 2020
Reviewers invited by journal
06 May, 2020
Editor assigned by journal
15 Apr, 2020
Submission checks completed at journal
14 Apr, 2020
Editor invited by journal
14 Apr, 2020
First submitted to journal
13 Apr, 2020

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Hospital transfer of people with dementia: results of the European RightTimePlaceCare project on their frequency, factors associated and costs

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Aim

Methods

Design

Participants

Procedures

Measures

Sample characteristics

Information on hospital transfer

Estimate of cost for hospital transfer

Statistical Analyses

Results

Sample characteristics

Hospital transfer

Factors associated with hospital transfer

Costs of hospital transfer

Discussion

Conclusions

Abbreviations

Declarations

References

Additional files

Supplementary Files

Status:

Journal Publication

Version 1