Do current discharge arrangements from inpatient hospital care for the elderly reduce readmission rates, the length of inpatient stay or mortality, or improve health status?

Summary

The issue

In the developed world, older people make up an increasing proportion of the population, and this demographic transition also affects some developing countries. In general, older people are at increased risk of disease, disability and financial and social deprivation compared to younger people in the same populations. For many older people, admission to an acute hospital is associated with a decline in physical functioning, which is not always recovered at the time of discharge, or even soon. Iatrogenic deterioration is not uncommon and, with extended stays, both informal and formal patterns of support at home may be disrupted and make a return to independent living extremely difficult. Thus, hospital discharge arrangements are a key issue in ensuring the safe and effective transfer of older people between inpatient hospital care, and community-based home care.

Findings

In a previous literature review in 2002, readmission was cited as a key undesirable outcome, and working across the health and social care interface as an important factor in reducing readmission rates after discharge from inpatient hospital care. This review updated searches for randomized controlled trials to January 2004, selecting studies that specifically considered discharge arrangements across the hospital-community divide, and reported readmission outcomes.

Evidence from 18 randomized controlled trials identified four main types of intervention: comprehensive geriatric assessment, discharge planning, discharge support and education. The conclusion is that discharge arrangements across the hospital-community interface are safe (not associated with increased mortality or other adverse outcomes) and that they reduce hospital readmission rates by about 20%. This is a worthwhile gain, particularly for older people at risk of repeated hospital admission. It can be achieved through the adoption of discharge practices spanning the hospital-community divide, based on the general models of care identified in this review.

Policy considerations

Key issues for the health, well-being and quality of life of older people include population based strategies for healthy ageing, the organization and delivery of primary care services, hospital-based care, alternatives to acute hospital admission and effective transfers of care between inpatient and community settings. Effective cooperation between health and social, hospital and community care systems is important, particularly where there is a risk of adverse outcomes from prolonged and unnecessary hospitalization. The organization and delivery of effective arrangements for discharging older people from inpatient hospital care is of central concern. The evidence presented here shows that effective and safe interventions, delivered across the hospital-community interface and associated with a reduction in the rate of readmission to hospital include:

• multidisciplinary teams using the principles of comprehensive geriatric assessment;
• discharge co-ordinators (usually a specialist or advanced practice nurse) using defined protocols;
• patient empowerment using educational approaches.

It should be noted that the evidence supporting these statements comes almost entirely from trials conducted in North America and Europe. Therefore, before deciding to introduce a specific form of discharge arrangement, the structure and organization of the local health and social care system needs to be carefully considered.

Type of evidence

The types of evidence used in this review comprised randomized controlled trials and meta-analyses.