1. The effects of person-based and hospital-based factors on outcomes of hospitalisation for people with dementia in NSW Australia
Brian Draper, Natalie Chan, Rosemary Karmel, Diane Gibson, Ann Peut, Charles Hudson, Phil Anderson, Kasia Bail, Laurie Grealish

2. (Draper et al, 2011; Watkin et al 2011; Mukadam & Sampson, 2011)
Background
People with dementia are high users of acute hospitals – approx 25% of persons with dementia in NSW hospitalised in 2006/7 (Draper et al, 2011)
Outcomes of people with dementia are worse than those without dementia
Longer LOS
Increased Mortality
Increased risk of Adverse Events
Increased risk of transfer to residential care
(Draper et al, 2011; Watkin et al 2011; Mukadam & Sampson, 2011)

3. Research Aim
To determine the influence of hospital- and community-based aged care and dementia services on outcomes of hospitalisation for people with dementia in the state of New South Wales (NSW), Australia in 2006/7.

4. NSW, Australia About 1100 kilometres Sydney
Population approx 7 million
198 public hospitals
About 1100 kilometres
Sydney

5. Methodology
Data from three sources were integrated to provide information about each patient and their first public hospital stay:
For demographic and clinical information, data were extracted from the NSW Admitted Patient Data Collection for 2006/7 (n = 252,719), including n= 20,800 with dementia.
Data about the availability of hospital-based aged care and dementia services and staff were obtained through a survey of NSW public hospitals (n =163, response rate 82%).
Regional provision levels of community-based care and residential care were extracted from the Aged and Community Care Management Information System

6. Methodology
Multiple linear analyses were undertaken to determine patient characteristics, hospital services and regional service provision factors associated with length of stay (LOS) for people with and without dementia.
Negative binomial distribution was used to account for skewness in LOS. Metric: days
Compared risk of death, residential aged care placement and inter-hospital transfers for people with and without dementia

7. Explanatory variables controlled for in analyses
Patient characteristics:
Demographics: age group, sex, marital status, socioeconomic status (SEIFA), country of birth, Aboriginal and/or Torres Strait Islander status
Health: Principal diagnosis, extent of comorbidity, principal procedure
Stay characteristics:
Admission day (weekday/weekend), inter-hospital transfer
Admitting hospital characteristics:
Size, rurality (major city/outside), hospital type (acute only/subacute), presence of preadmission services, presence of emergency department with or without specialist aged care staff)
Hospital characteristics during stay:
Specialist staff: Specialist medical aged care staff (Permanent, visiting or none), interface position
Policies: Dementia, delirium
Staff education: Dementia forums
Facilities: Secure beds, rehabilitation beds, residential aged care beds
Services: Memory clinic, respite services, day hospitals, post-discharge services (last hospital)
Discharge destination:
Returned to community, new admission to RAC, return to RAC, died, other
These slides list variables that were included in the multiple regression. Any significant finding exists after controlling for all these variables.
So, we controlled for demographic factors including age group, sex, marital status, socioeconomic status, country of birth and Aboriginal and Torres Strait Islander status.
We also controlled for patient’s primary reason for admission, extent of comorbidity and the principal procedure that they received in their first episode.
Admission day was added as there is some literature that shows this influences LOS (King et al, 2006).
Principal diagnoses were categorised as the following:
firstpdiag1=
'Certain infectious & parasitic '
firstpdiag2 =
'Neoplasms '
firstpdiag3 =
'Blood & blood forming organs‘: REFERENCE GROUP
firstpdiag4 =
'Endocrine, nutritional, metabolic & immunity , excluding diabetes'
firstpdiag5=
'Diabetes '
firstpdiag6 =
'Dementia'
firstpdiag7 =
'Delirium'
firstpdiag8 =
'Depressive disorders'
firstpdiag9 =
'Other mental and behavioural disorders'
firstpdiag10 =
'Nervous system, excluding dementia'
firstpdiag11 =
Eye and adnexa
firstpdiag12 =
'Ear and mastoid process'
firstpdiag13=
'Other circulatory system diseases'
firstpdiag14=
'Heart disease'
firstpdiag15 =
'Cerebrovascular disease'
firstpdiag16 =
'Chronic bronchitis/emphysema/chronic airways'
firstpdiag17=
'Lower respiratory tract'
firstpdiag18 =
'Other repiratory system diseases'
firstpdiag19=
'Liver diseases'
firstpdiag20 =
'Digestive system diseases'
firstpdiag21=
'Skin and subcutaneous tissue diseases'
firstpdiag22=
'Arthritis'
firstpdiag23 =
'Musculoskeletal system diseases'
firstpdiag24 =
'Urinary Tract Infections'
firstpdiag25 =
'Other genitourinary system diseases'
firstpdiag26 =
'Congenital anomalies'
firstpdiag27 =
'Symptoms, signs and ill-defined conditions'
firstpdiag28 =
'Fractures'
firstpdiag29 =
'Injury and poisoning'
firstpdiag30=
'External cause code'
firstpdiag31 =
'Awaiting admission to adequate facility elsewhere'
firstpdiag32 =
'Factors influencing health status and contact with health services'

8. Age, Dementia Status & LOS
Dementia Mean LOS = 16.5 days, Median = 7 days
Without Dementia Mean LOS = 8.9 days, Median = 4 days
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Age Group
65-74 years
50-64 yrs
-0.12***
0.24***
75-84 yrs
0.17***
-0.03
85 yrs and over
0.28***
-0.09**
For people without dementia, increasing age is associated with longer hospital stays. In contrast, for people with dementia, increasing age is associated with shorter hospital stays.
** p<.01; *** p<.001

9. Demographics, Dementia Status & LOS
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Sex
Female
Male
-0.01
0.03
Marital Status
Unpartnered
Partnered
0.14***
SES (SEIFA)
0.00*
Country of birth
Australia
Overseas: English speaking country
-0.06***
0.06
OS: Non-English speaking country
-0.04***
-0.03
Aboriginal and/or Torres Strait Islander
Neither
Yes
-0.06*
-0.35**
Sex was not associated with length of stay for people with or without dementia.
Having a partner was related to a longer stay for people without dementia but not an influencing factor for people with dementia.
Greater socioeconomic advantage was associated with slightly longer stays for people without dementia, but was not related to LOS for people with dementia.
Compared with Australian-born people, people without dementia who were born overseas had shorter stays. COB was not a significant predictor of LOS for people with dementia.
Being Aboriginal and/or Torres Strait Islander was associated with shorter stays for both people with and without dementia. (This may reflect their greater social support networks?)
* p<.05; ** p<.01; *** p<.001;

10. Principal diagnoses with Strongest Influence on LOS
Person Characteristics
Without Dementia
With Dementia
Principal diagnosis
Depressive disorders
Other mental and behavioural disorders
Factors influencing health status and contact with health services
Fractures
Awaiting admission to adequate facility elsewhere
The top 5 principal diagnoses that were associated with the longest lengths of stay, after controlling for all the other variables are listed here.

11. Characteristics of hospital stay & LOS
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Extent of Comorbidity
Charleson Index
0.19***
0.12***
Principal procedure
Surgical
Medical
-0.21***
-0.39***
Admission day
Weekday
Weekend
0.03***
-0.07**
Inter-hospital transfer
Yes
1.00***
0.92***
Greater comorbidity was related to longer stays for both people with and without dementia.
We also controlled for the influence of procedures on LOS. Receiving a medical as opposed to a surgical procedure was associated with shorter stays for both people with and without dementia.
In regards to day of admission, being admitted on the weekend was significantly related to a longer length of stay for people without dementia. In contrast, it was the opposite pattern for people with dementia. (Tried running the analysis for people with dementia according to whether they were in residential care and found no difference)
Inter-hospital transfers were related to longer LOS for both people with and without dementia. There’s no difference in strength.
* p<.05; ** p<.01; *** p<.001

12. Admitting hospital characteristics & LOS
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Size
0-99 beds
beds
0.09***
-0.03
beds
0.30***
-0.01
>400 beds
0.31***
0.01
Rurality
Major city
Outside
-0.04
Type
Acute only
Subacute
0.40***
0.59***
Preadmission services
None
Yes
0.04***
0.09**
Emergency department (ED) with specialist aged care staff
No ED
ED, but no specialist aged care staff
-0.15***
ED with specialist aged care staff
For some variables we needed to pick a particular hospital, as opposed to ask if the stay ever involved…
For people without dementia, being admitted to a larger hospital was associated with longer stays. Size of hospital was not an influencing factor on LOS for people with dementia.
Surprisingly, rurality of hospital was not a significant predictor of LOS for either people with or without dementia. Perhaps it is because we have controlled for other factors that usually distinguish hospital in and outside major cities?
We also controlled for the type of hospital. As expected, staying in a hospital that provide subacute services was associated with longer LOS for both groups of people.
Stays in hospitals with preadmission services were associated with longer LOS for both people with and without dementia. Is this because people with less severe conditions are no longer admitted to these hospitals? The strength of the relationship is not significantly different for people with and without dementia.
For people without dementia, staying in a hospital with an emergency department either with or without specialist aged care staff was associated with shorter stays. In contrast, these factors were not significant predictors of LOS for people with dementia.
* p<.05; ** p<.01; *** p<.001;

13. Specialist staff, policies, education
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Specialist aged care medical staff
None
Permanent
-0.12***
-0.15*
Visiting
-0.09***
-0.09
Specialist interface position
Yes
-0.01
0.05
Dementia policy
0.08***
0.17***
Delirium policy
-0.02
-0.11*
Dementia education forum
-0.08***
-0.20***
In regards to specialist medical and nursing staff, having specialist medical aged care staff was associated with shorter LOS for both people with and without dementia. Having a specialist interface staff member was not related to LOS for people with or without dementia, although there was a trend for people with dementia suggesting that it may be related to LOS.
That having a dementia policy was related to longer lengths of stay is a curious finding. Perhaps these hospitals have more people with dementia?
Having a policy about delirium was related to shorter stays whereas having a dementia education forum was associated with shorter stays.
 p<.1; * p<.05; ** p<.01; *** p<.001;

14. Services and facilities
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Secure beds
None
Yes
-0.04***
-0.01
Memory clinic
0.04***
0.13**
Rehabilitation beds for people with dementia
0.10***
0.17***
RAC beds on site
0.01
-0.11*
Respite services
-0.05***
-0.02
Day hospitals/ community rehabilitation centres
0.04
Services and facilities:
There was no significant relationship between secure beds and LOS for people with dementia.
The presence of a memory clinic was related to longer stays for people with and without dementia, as was the presence of rehabilitation beds for people with dementia.
The presence of residential aged care beds for people with dementia was related to shorter stays.
The presence of respite services and day hospitals were related to shorter stays for people without dementia only.
*RAC beds x age x waiting for placement
* p<.05; ** p<.01; *** p<.001;

15. Regional aged care provision
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Residential aged care beds
Lowest quintile
2nd quintile
0.07***
0.08*
3rd quintile
0.03***
0.00
4th quintile
0.05***
5th quintile
0.01
0.03
Community packages
-0.01
-0.07*
0.06
For people without dementia, the pattern seems to suggest that higher provision of residential aged care beds in the community was related to longer hospital stays. This pattern was only evidence for areas in the second quintile as compared to the lowest for people without dementia.
Provision level of community packages was not related to LOS for people without dementia. For people with dementia, the only significant result pertained to the comparison between the lowest and second lowest provision quintile. Compared with the lowest provision quintile, stays in areas with the next highest level of provision were shorter.
* p<.05; ** p<.01; *** p<.001;

16. Discharge hospital and destination
Explanatory Variable
Reference Group
Other Groups
Without Dementia
With Dementia
Post-discharge services
None
Yes
-0.01
0.03
Discharged destination
Return to community
New admission to RAC
1.20***
0.80***
Return to RAC
0.03*
-0.30***
Died
0.40***
0.07
Othera
0.14***
0.36***
The presence of post-discharge hospital services was not related to LOS for people with or without dementia.
Compared with people returning to the community, being newly admitted to residential aged care was associated with a longer stay.
Returning to RAC was related to longer stays for people without dementia but shorter stays for people with dementia.
Dying in hospital was associated with longer stays for both people with and without dementia.
a. Other: Reported as transfer to other, psychiatric hospital, hospital or unknown;  p<.1; * p<.05; ** p<.01; *** p<.001;

17. Summary
LOS is influenced by various patient, diagnostic, hospital and community service factors
Some factors have similar effects on LOS of people with and without dementia e.g. Comorbidity, policies, hospital transfers
Other factors have different effects on people with and without dementia

18. Summary For people with dementia: For people without dementia:
LONGER: Being younger
SHORTER: Admitted on weekend, RAC beds in hospital, being a RAC resident
For people without dementia:
LONGER: being older, married, admitted on weekend, larger hospital, greater RAC provision in community, being a RAC resident
SHORTER: presence of ED, secure beds, respite services and a day hospital

19. Future directions
Hospital- and community- factors that are associated with likelihood of admission to RAC and death in hospital
Multi-level modelling approach to allow the differential influence of factors at the stay, patient and hospital level on hospitalisation outcomes to be examined.

20. Thank you……. Any questions? Contact us:
Web:
Brian Draper: