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

2. 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

3. 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

4. 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

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

6. 1. Overview of hospital activity

7. 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

8. 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
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

9. 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

10. 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.)

11. 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

12. 2. Hospital admissions in older adults

13. Numbers and proportions of people that died in hospital following a <30 day admission by underlying cause of death and older age group,
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

14. 3. Causes and contributory causes of death

15. 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
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

16. 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
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

17. 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
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

18. 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

19. 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

20. 4. Geographical Variation -by local authority

21. 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
Stroke hospital deaths
Cancer hospital deaths

22. 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
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

23. 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
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

24. 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.

25. 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.

26. 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: /

27. END