Ingold B B, Yersin B, Wietlisbach V, Burckhardt P, Bumand B, Büla C J
Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
Aging (Milano). 2000 Dec;12(6):430-8. doi: 10.1007/BF03339873.
Our objective was to identify patient characteristics associated with inappropriate hospital days in a cohort of elderly medical inpatients. This prospective cohort study included a total of 196 patients aged 75 years and older, who were consecutively admitted over eight months to the internal medicine service of a regional, non-academic public hospital located in a rural area of Western Switzerland. Patients with severe cognitive impairment, terminal disease, or previously living in a nursing home were excluded. Data on demographics, medical, physical, social and mental status were collected at admission. A blinded hospitalization review was performed concurrently using a modified version of the Appropriateness Evaluation Protocol (AEP). Subjects' mean age was 82.4 years; 63.3% were women. Median length of stay was 8 days. Overall, 68 patients (34.7%) had at least one inappropriate day during their stay, including 18 patients (9.2%) whose hospital admission and entire stay were considered inappropriate. Most inappropriate days were due to discharge delays (87.10%), primarily to nursing homes (59.30%). Univariate analysis showed that subjects with inappropriate days were more likely to be living alone (69.1 vs 48.4%, p=0.006), and receiving formal in-home help (48.5 vs 32.8%, p=0.031). In addition, they were more impaired in basic and instrumental activities of daily living (BADLs, and IADLs, p<0.001 and p=0.015, respectively), and more frequently had a depressed mood [29.4 vs 10.9%, p=0.001 with a score > 6 at the Geriatric Depression Scale (GDS), short form]. Using multivariate analysis, independent associations remained for patients living alone (OR 2.6, 95%CI 1.2-5.8, p=0.016), those with a depressed mood (OR 2.8, 95%CI 1.1-7.3, p=0.032), with BADL dependencies (OR 1.5, 95%CI 1.2-1.8, p=0.001), and IADL dependencies (OR 1.3, 95%CI 1.0-1.6, p=0.032). Cardiovascular (OR 0.2, 95%CI 0.1-0.7, p=0.008) and pulmonary admission diagnoses (OR 0.1, 95%CI 0.0-0.7, p=0.022) were inversely associated with inappropriate hospital days. In conclusion, patients living alone, functionally impaired and showing depressive symptoms were at increased risk for inappropriate hospital days. These characteristics might permit better targeting for early discharge planning in these at-risk subjects, and contribute to avoiding premature discharge of other vulnerable elderly patients. Whether these interventions for at-risk patients will also result in prevention of hospitalization hazards, such as deconditioning and related functional decline, will require further study.
我们的目标是确定老年内科住院患者队列中与不适当住院天数相关的患者特征。这项前瞻性队列研究共纳入了196名75岁及以上的患者，他们在八个月的时间里连续入住瑞士西部农村地区一家非学术性地区公立医院的内科。排除患有严重认知障碍、终末期疾病或之前住在养老院的患者。在入院时收集了人口统计学、医疗、身体、社会和精神状态的数据。同时使用改良版的适宜性评估方案（AEP）进行了盲法住院审查。受试者的平均年龄为82.4岁；63.3%为女性。中位住院时间为8天。总体而言，68名患者（34.7%）在住院期间至少有一天不适当，其中18名患者（9.2%）的住院和整个住院期间被认为是不适当的。大多数不适当的天数是由于出院延迟（87.10%），主要是延迟到养老院（59.30%）。单因素分析显示，有不适当天数的受试者更有可能独居（69.1%对48.4%，p=0.006），并接受正式的居家帮助（48.5%对32.8%，p=0.031）。此外，他们在基本日常生活活动和工具性日常生活活动方面受损更严重（分别为BADLs和IADLs，p<0.001和p=0.015），并且更频繁地出现情绪低落[老年抑郁量表（GDS）简表得分>6时，29.4%对10.9%，p=0.001]。使用多因素分析，独居患者（OR 2.6，95%CI 1.2 - 5.8，p=0.016）、情绪低落患者（OR 2.8，95%CI 1.1 - 7.3，p=0.032）、有BADL依赖的患者（OR 1.5，95%CI 1.2 - 1.8，p=0.001）和有IADL依赖的患者（OR 1.3，95%CI 1.0 - 1.6，p=0.032）仍存在独立相关性。心血管疾病（OR 0.2，95%CI 0.1 - 0.7，p=0.008）和肺部入院诊断（OR 0.1，95%CI 0.0 - 0.7，p=0.022）与不适当住院天数呈负相关。总之，独居、功能受损且有抑郁症状的患者出现不适当住院天数的风险增加。这些特征可能有助于更好地针对这些高危受试者进行早期出院计划，并有助于避免其他脆弱老年患者过早出院。针对高危患者的这些干预措施是否也能预防住院风险，如身体机能下降和相关功能衰退，还需要进一步研究。
