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, 2004-08 by place of death and underlying cause of death Elsewhere Hospice Hospital Nursing Home Old Peoples Home Own Residence Grand Total Cancer 1 17 48 6 3 24 100 Cardiovascular 58 28 Other 4 61 11 9 14 Respiratory 68 8 13 Stroke 66 16 10 7 2 5 19 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 2004-08 = 2,381,055 Total LMF deaths in England 2004-08 = 2,173,458 (91%) Total LYLC deaths in England 2004-08 = 1,803,586 (77%) Approximately 50,000 records were excluded for not successfully linking the full death record

Underlying cause of death 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 2004-08 Underlying cause of death Total ONS Deaths 12 months before death 6 months 3 months 1 month n % Cancer 636,373 563,161 88% 533,844 84% 485,216 76% 336,296 53% Cardiovascular 526,354 347,373 66% 316,295 60% 286,487 54% 221,233 42% Stroke 229,258 172,441 75% 161,371 70% 148,145 65% 112,850 49% Respiratory 330,145 260,045 79% 245,134 74% 229,094 69% 182,983 55% Other 658,925 460,566 426,106 388,452 59% 291,852 44% Total 2,381,055 1,803,586 1,682,750 71% 1,537,394 1,145,214 48% Source: Office for 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 2004-08 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, 2004-08 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 2004-08 Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics Peak in admissions for hospital deaths 24-48 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, 2004-08 UL Cause of death Total deaths 0-30 days Age at death 75-79 80-84 85+ 75+ n % Cancer 237,484 41,450 17% 39,897 39,010 16% 120,357 51% Cardiovascular 190,436 29,659 42,867 23% 76,409 40% 148,935 78% Stroke 104,783 15,626 15% 23,380 22% 42,413 81,419 respiratory 166,278 25,794 36,615 66,855 129,264 Other 254,725 33,879 13% 48,057 19% 91,147 36% 173,083 68% Total 953,706 146,408 190,816 20% 315,834 33% 653,058 Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

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 2004-08 *Proportions are of all deaths in 0-30 day admissions Disease Underlying cause Contributory Mentions (UL + Cont) n % Acute Heart 139,848 14.7 103,813 10.9 243,661 25.5 Aortic Aneurism 12,755 1.3 2,526 0.3 15,281 1.6 Chronic Heart 28,645 3.0 99,041 10.4 127,686 13.4 COPD 74,558 7.8 49,369 5.2 123,927 13.0 Dementia-Alzheimers-Senility 23,023 2.4 81,483 8.5 104,506 11.0 Diabetes mellitus 6,521 0.7 36,930 3.9 43,451 4.6 Falls 9,293 1.0 2,771 12,064 Neurodegenerative Disease 10,363 1.1 7,844 0.8 18,207 1.9 Pneumonitis due to food & vomit 8,412 0.9 26,935 2.8 35,347 3.7 Pneumonia/Acute respiratory 73,700 7.7 173,978 18.2 247,678 26.0 Renal Disease 12,203 69,448 7.3 81,651 8.6 Stroke 103,882 41,258 4.3 145,140 15.2 Urinary tract infection, site unspecified 18,033 26,465 44,498 4.7 Other (excludes nulls) 432,470 - Grand Total 953,706 721,861 1,243,097 Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

Table of persons that died in hospital during an admission of 0-30 days, by disease type, England 2004-08 *Proportions are of all deaths in 0-30 day admissions Disease Underlying cause Contributory Mentions (UL + Cont) n % Acute Heart 139,848 14.7 103,813 10.9 243,661 25.5 Aortic Aneurism 12,755 1.3 2,526 0.3 15,281 1.6 Chronic Heart 28,645 3.0 99,041 10.4 127,686 13.4 COPD 74,558 7.8 49,369 5.2 123,927 13.0 Dementia-Alzheimers-Senility 23,023 2.4 81,483 8.5 104,506 11.0 Diabetes mellitus 6,521 0.7 36,930 3.9 43,451 4.6 Falls 9,293 1.0 2,771 12,064 Neurodegenerative Disease 10,363 1.1 7,844 0.8 18,207 1.9 Pneumonitis due to food & vomit 8,412 0.9 26,935 2.8 35,347 3.7 Pneumonia/Acute respiratory 73,700 7.7 173,978 18.2 247,678 26.0 Renal Disease 12,203 69,448 7.3 81,651 8.6 Stroke 103,882 41,258 4.3 145,140 15.2 Urinary tract infection, site unspecified 18,033 26,465 44,498 4.7 Other (excludes nulls) 432,470 - Grand Total 953,706 721,861 1,243,097 Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

Table of persons that died in hospital during an admission of 0-30 days, by disease type, England 2004-08 *Proportions are of all deaths in 0-30 day admissions Disease Underlying cause Contributory Mentions (UL + Cont) n % Acute Heart 139,848 14.7 103,813 10.9 243,661 25.5 Aortic Aneurism 12,755 1.3 2,526 0.3 15,281 1.6 Chronic Heart 28,645 3.0 99,041 10.4 127,686 13.4 COPD 74,558 7.8 49,369 5.2 123,927 13.0 Dementia-Alzheimers-Senility 23,023 2.4 81,483 8.5 104,506 11.0 Diabetes mellitus 6,521 0.7 36,930 3.9 43,451 4.6 Falls 9,293 1.0 2,771 12,064 Neurodegenerative Disease 10,363 1.1 7,844 0.8 18,207 1.9 Pneumonitis due to food & vomit 8,412 0.9 26,935 2.8 35,347 3.7 Pneumonia/Acute respiratory 73,700 7.7 173,978 18.2 247,678 26.0 Renal Disease 12,203 69,448 7.3 81,651 8.6 Stroke 103,882 41,258 4.3 145,140 15.2 Urinary tract infection, site unspecified 18,033 26,465 44,498 4.7 Other (excludes nulls) 432,470 - Grand Total 953,706 721,861 1,243,097 Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

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 2004-08 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 2004-08 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

Stroke hospital deaths Cancer hospital deaths Age standardised Proportions of deaths in hospital after being admitted in the final month of life, for stroke and cancer deaths, England 2004-08 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 2004-08 Rates of deaths in hospital following an admission of 0-30 days Underlying Cause of death Local Authority Age Standardised Proportions England Average All Causes Highest Doncaster 63% 52% Lowest Tunbridge Wells 30% Cancer 68% 48% 23% Cardiovascular disease North Dorset 64% 53% 31% Respiratory disease Harlow 72% 62% Torridge 36% Stroke Southend-on-Sea 66% 54% 27% Other Portsmouth 51% North Devon 29% Source: Linked Mortality File, Office for National Statistics, annual mortality file and NHS Information Centre, Hospital Episode Statistics

Age standardised Proportions of deaths in hospital after being admitted in the final month of life, England 2004-08 Local Authority Standardised proportions of deaths with 0-30 day admission before death in hospital Cancer Cardiovascular Respiratory Stoke Others All causes % rank Mid Sussex 33 15 47 40 62 208 9 45 18 42 8 Burnley 48 190 51 121 59 120 56 246 53 214 200 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 2004-08 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 38072.481933.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:10.1186/1472-6963-7-69

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