Hospital admissions in the last year of life and death in hospital P Lyons & J Verne, South West Public Health Observatory

Intro and Aims: To examine pattern of hospital admissions in the year prior to death To inform models of costing the hospital inpatient component of end of life care Broad disease categories Subsequent reports for more specific disease groups and causes of death

Proportion of total patients that have died, by place of death and underlying cause of death Underlying cause of death Place of Death (%) ElsewhereHospiceHospitalNursing Home Old Peoples Home Own ResidenceGrand Total Cancer Cardiovascular Other Respiratory Stroke Grand Total Source: Office for National Statistics, annual mortality extracts

Data sources Same definitions as previous studies; broad definitions of underlying cause of death and place of death. Linked mortality file (LMF) –Office of National Statistics (ONS)- Annual public health mortality extract –The NHS Information Centre (IC)- performs a link to Hospital Episode Statistics (HES) data –We receive information from death certificate with HES id and link to our database of all HES inpatient hospital activity. Last year of life cohort – only people that had an admission in final year of life

Results Overview of hospital activity Hospital admission in older adults Causes of death & co-morbidities Geographical variation -by local authority

1. Overview of hospital activity

Overall number of patients Total ONS deaths in England = 2,381,055 Total LMF deaths in England = 2,173,458 (91%) Total LYLC deaths in England = 1,803,586 (77%) –Approximately 50,000 records were excluded for not successfully linking the full death record

Table 2: to show the number and percentage of all deaths that have at least one admission in the last 12,6,3 and 1 month/s of life before death, by cause of death, England Underlying cause of death Total ONS Deaths 12 months before death 6 months3 months1 month n%n%n%n% Cancer 636,373563,16188%533,84484%485,21676%336,29653% Cardiovascular 526,354347,37366%316,29560%286,48754%221,23342% Stroke 229,258172,44175%161,37170%148,14565%112,85049% Respiratory 330,145260,04579%245,13474%229,09469%182,98355% Other 658,925460,56670%426,10665%388,45259%291,85244% Total 2,381,0551,803,58676%1,682,75071%1,537,39465%1,145,21448% Source: Office fo r National Statistics, annual mortality extracts

Numbers of patients that had at least one admission in the last 12,6,3 and 1 month/s of life, by cause of death, England Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Cancer highest average no. of admissions (5 per person) Half of all bed days received in final year of life admitted in the 3 months before death

Average length of stay per admission by underlying cause of death in patients that have had an admission 12, 6, 3 and 1 month/s before death, Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Stroke patients highest average length of stay (16 days per admn.) Cancer patients have the lowest (peak at 8 days per admn.)

Figure 2: Frequency distribution of lengths of stay prior to death in hospital (up to 30 days) by underlying cause of death, England Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Peak in admissions for hospital deaths hrs before death Approx. 90% of these final admissions are Emergencies

2. Hospital admissions in older adults

Numbers and proportions of people that died in hospital following a <30 day admission by underlying cause of death and older age group, Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics UL Cause of death Total deaths days Age at death n%n%n%n% Cancer 237,48441,45017%39,89717%39,01016%120,35751% Cardiovascular 190,43629,65916%42,86723%76,40940%148,93578% Stroke 104,78315,62615%23,38022%42,41340%81,41978% respiratory 166,27825,79416%36,61522%66,85540%129,26478% Other 254,72533,87913%48,05719%91,14736%173,08368% Total 953,706146,40815%190,81620%315,83433%653,05868%

3. Causes and contributory causes of death

Table of persons that died in hospital during an admission of 0-30 days, by disease type, England *Proportions are of all deaths in 0-30 day admissions Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Disease Underlying causeContributoryMentions (UL + Cont) n%n%n% Acute Heart 139, , , Aortic Aneurism 12, , , Chronic Heart 28, , , COPD 74, , , Dementia-Alzheimers-Senility 23, , , Diabetes mellitus 6, , , Falls 9, , , Neurodegenerative Disease 10, , , Pneumonitis due to food & vomit 8, , , Pneumonia/Acute respiratory 73, , , Renal Disease 12, , , Stroke 103, , , Urinary tract infection, site unspecified 18, , , Other (excludes nulls) 432,470-- Grand Total 953,706721,8611,243,097

Table of persons that died in hospital during an admission of 0-30 days, by disease type, England *Proportions are of all deaths in 0-30 day admissions Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Disease Underlying causeContributoryMentions (UL + Cont) n%n%n% Acute Heart 139, , , Aortic Aneurism 12, , , Chronic Heart 28, , , COPD 74, , , Dementia-Alzheimers-Senility 23, , , Diabetes mellitus 6, , , Falls 9, , , Neurodegenerative Disease 10, , , Pneumonitis due to food & vomit 8, , , Pneumonia/Acute respiratory 73, , , Renal Disease 12, , , Stroke 103, , , Urinary tract infection, site unspecified 18, , , Other (excludes nulls) 432,470-- Grand Total 953,706721,8611,243,097

Table of persons that died in hospital during an admission of 0-30 days, by disease type, England *Proportions are of all deaths in 0-30 day admissions Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Disease Underlying causeContributoryMentions (UL + Cont) n%n%n% Acute Heart 139, , , Aortic Aneurism 12, , , Chronic Heart 28, , , COPD 74, , , Dementia-Alzheimers-Senility 23, , , Diabetes mellitus 6, , , Falls 9, , , Neurodegenerative Disease 10, , , Pneumonitis due to food & vomit 8, , , Pneumonia/Acute respiratory 73, , , Renal Disease 12, , , Stroke 103, , , Urinary tract infection, site unspecified 18, , , Other (excludes nulls) 432,470-- Grand Total 953,706721,8611,243,097

Number of Pneumonia/ acute respiratory diseases, underlying causes of death and mentions by age group for deaths in hospital with an admission of <30 days, England Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Quarter of all hospital deaths with final admission in last month had a mention pneumonia/ acute respiratory on death certificate

Number of renal diseases, underlying causes of death and mentions by age group for deaths in hospital with an admission of <30 days, England Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics High numbers of patients with renal disease as co-morbidity at end of life

4. Geographical Variation -by local authority

Age standardised Proportions of deaths in hospital after being admitted in the final month of life, for stroke and cancer deaths, England Stroke hospital deaths Cancer hospital deaths

Local Authorities to show highest and lowest proportions of deaths in hospital following a hospital admission of 0-30 days by local authority and underlying cause (standardised for age and sex), England Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Rates of deaths in hospital following an admission of 0-30 days Underlying Cause of deathLocal AuthorityAge Standardised ProportionsEngland Average All Causes Highest Doncaster63% 52% Lowest Tunbridge Wells30% Cancer Highest Doncaster68% 48% Lowest Tunbridge Wells23% Cardiovascular disease Highest North Dorset64% 53% Lowest Tunbridge Wells31% Respiratory disease Highest Harlow72% 62% Lowest Torridge36% Stroke Highest Southend-on-Sea66% 54% Lowest Torridge27% Other Highest Portsmouth62% 51% Lowest North Devon29%

Age standardised Proportions of deaths in hospital after being admitted in the final month of life, England Local Authority Standardised proportions of deaths with 0-30 day admission before death in hospital CancerCardiovascularRespiratoryStokeOthersAll causes %rank% % % % % Mid Sussex Burnley Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

Summary 78% of people that died in England had at least one admission to hospital in their last year of life. A fifth of all bed days received in the final year of life occur in the last 30 days. Emergency admissions rise exponentially in the final few days of life for patients that die in hospital. 75% of people that die in hospital following an admission in the last month of life have a mention of a small list of just 13 conditions. The quality of healthcare a person receives at the end of their life varies depending on where they live.

Discussion & future work Pneumonia/Acute respiratory disease and Acute heart disease require closer inspection as most common conditions found on death certificates. Co-morbidities renal disease, dementia, alzheimers & senility and chronic heart disease. Two people that suffer from the same chronic condition have an equal right to well planned management of their illness no matter where they live in the country. Improved planning at an earlier stage of illness leads to fewer short hospital admissions and fewer deaths in hospital.

References Bowers B et al (2010) - Improving integrated team working to support people to die in the place of their choice. Nursing Times; 106: 32, early online publication Dixon T, Shaw M, Frankel S & Ebrahim S (2004) - Hospital admissions, age, and death: retrospective cohort study, BMJ EE Van den Block L, Deschepper R, Drieskens K, Bauwens S, Bilsen J, Bossuyt N & Deliens L. (2007) - BMC Health Services Research 2007, 7:69 doi: /

END