PAHA: Preventing Avoidable Hospital Admissions for People with Dementia

Background

• 5% of all hospitalisations in Australia are potentially avoidable if conditions were managed earlier. These are known as ambulatory care sensitive (ACS) conditions.
• Older Australians make up 14-27% of all potentially avoidable hospitalisations.
• Compared to age-matched peers, people with dementia are at greater risk of ACS conditions; have 2x rate of hospitalisation; have more long-term health conditions (5.4 vs 2.9), and 2-3x more likely to have poor outcomes from hospitalisation.
• 75% of dementia-related hospitalisations are from those living in the community.

Design

Retrospective audit of 150 Emergency Department (ED) records of people with dementia living in the community across 3 Melbourne hospitals.

Survey of 24 staff from 2 Melbourne hospitals regarding practices and attitudes towards people with dementia and their carers who attend the ED.

Systematic review of the effectiveness of carer interventions in reducing avoidable hospitalisations for people with dementia.

Themes & Key Findings

• Most presentations were not considered avoidable at the time of ED presentation
• A large proportion of ED presentations were considered to be avoidable in the days/weeks prior
• Carer interventions appear to have some short-term impact on carer wellbeing, but have little impact on rates of hospitalisation for people with dementia.

Results

• ED records did not contain clear information about dementia status (37% dementia type unknown)
• People with dementia have multiple comorbidities
• Pain & falls are the most common reasons for ED presentation
• Most presentations (59%) were not considered avoidable at the time of ED presentation
• A large proportion (85%) of ED presentations were considered to be avoidable in the days/weeks prior
• Staff perceptions differ from actual reasons for ED presentation. Most (96%) staff agreed that hospital was a risk to people with dementia. However, 87% reported that people with dementia are a major problem for the health service.
• 15/17 studies showed no effect on hospitalisation rates. 2 studies found a significant reduction in hospitalisation: 1 low quality study and 1 RCT that showed improvement in ED presentations but not admissions in a subgroup of participants.
• Some benefit of interventions on carer wellbeing but they were not sustained.

Recommendations

• Need to improve the suitability of hospitals for people with dementia to minimise impact when acute care is needed.
• Interventions should focus on optimising the physical health of people with dementia to minimise the longer-term need for hospitalisation.
• Carer and GP perspectives were not included in this study. Exploration of carer experiences and GP practices is warranted.

Completed September 2018