Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases

Abstract

Background Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care. Methods A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors. Results The cohort comprised 76,704 adults with median age 81 years (IQR 70–88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0–28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90–7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78–6.62]), dementia (aHR 5.07 [95% CI 3.80–6.77]) and liver disease (aHR 9.75 [95% CI 6.50–14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04–1.39]) compared with cancer ‘other’. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36–2.79]) and cancer (aHR 2.59 [95% CI 2.13–3.15]) (reference: lowest). Conclusions One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.

Could it have been predicted? A retrospective analysis of the last year of life for people who died whilst in an intermediate care centre

“…20 It is well documented that number of hospital admissions increase as people near the end of life and this is often used as a measure to identify such people. 7 However, this paper suggests this does not translate to people admitted to an ICC for rehabilitation; the majority of whom (71%) had no prior admissions that year ( Fig. 5 ).…”

“… 5 , 6 A national study of over 76,000 people admitted to an ICC showed 25% died within a year of admission, highlighting the need to integrate end-of-life care planning alongside rehabilitation in this cohort. 7 This compares to a mortality of 38% following admission to an acute geriatric ward. 8 There are a number of tools to aid prognostication 9 , 10 , 11 , 12 , 13 ; and although these all provide evidence-based guidance as to when a person is likely to be in the last months of life, there is no clear guidance as to who should be carrying out these scores, how often and in which environment.…”

“… 8 There are a number of tools to aid prognostication 9 , 10 , 11 , 12 , 13 ; and although these all provide evidence-based guidance as to when a person is likely to be in the last months of life, there is no clear guidance as to who should be carrying out these scores, how often and in which environment. Despite increasing recognition of poor prognoses exhibited by ICC in-patients 7 there has been little examination of the predictability of deterioration in this cohort ( Fig. 1 ).…”

Delirium in geriatric rehabilitation: the continued case of B.M

“…In addition, they experience precipitating factors that contribute significantly to delirium development, like a hip fracture (around 12-51% incident delirium), a stroke (33% incident delirium), a surgery (13-50% incident delirium) or being in the Intensive Care Unit (19-82% incident delirium) 5 . Despite all these risk factors, delirium prevalence in older patients in these settings ranges from 6-40%, according to studies [3][4][5][6][7][8][9] . Despite the increased availability of intermediate care services, which has led to more publications about delirium in these settings, there is still a lack of literature regarding delirium in intermediate care settings, and the evidence available is still very limited.…”

Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: a discrete choice experiment and stakeholder consultations

“…These facilities care for mainly adults aged 80 years and over, with multimorbidity, where uncertainty is inherent, and following an unplanned admission. Over one in four die within a year of their index admission [ 20 ]. These settings are key for older people to support recovery and rehabilitation, and plan for and anticipate nearness of end of life [ 21 , 22 ].…”