Prevalence, determinants and practical implications of inappropriate hospitalizations in older subjects: A prospective observational study


      • Hospitalization rate increases with age, along with greater risks of adverse events.
      • Clinical and economic burden of inappropriate hospitalizations on healthcare system.
      • Mainly accounted for by frail older patients no longer manageable at home.
      • Need for an improvement of home and residential interventions and supports.


      In a context of high demand for hospital services among older people, we aimed to assess the rate and determinants of inappropriate hospitalizations of older patients, and to what extent they were associated with inappropriate hospital stay.
      This prospective observational multicentre study evaluated a random sample of consecutive patients aged ≥ 70 years accessing the Emergency Department (ED) of two Italian tertiary hospitals. A standardized comprehensive geriatric assessment was carried out in each patient, including the Blaylock Risk Assessment Screen Scale (BRASS) for identification of patients at risk of difficult discharge. Inappropriate hospitalization was defined by the ED physician when patients did not necessitate hospital-provided procedures but was due to social reasons or lack of an alternative care-setting.
      Among 1877 patients (median age 80.7 years, 50.1% male), with a high prevalence of functional dependence and social isolation (around 30% and 25%, respectively), 767 (40.9%) were hospitalized. Incidence of inappropriate hospitalization was 14.6% (95% CI 12.1%-17.1%) and was associated with moderate-high risk of difficult discharge at BRASS (OR = 1.98, 95% CI 1.16-3.39, p = 0.013) and the presence of dementia with behavioural disorders (OR = 1.79, 95% CI 1.10-2.91, p = 0.020). Compared with patients appropriately admitted, inappropriate hospitalizations had shorter length of hospital stay but accounted for 1059/9154 days of stay (11.6%).
      Inappropriate hospitalizations occurred in less than 15% of cases, mainly accounted for by patients no longer manageable at home, but contributed to the greatest proportion of inappropriate hospital stay. These findings highlight the need of implementing appropriate home-care services and ensuring rapid access to suitable care-facilities for community-dwelling frail older patients.



      A.Di.Co. (“Area Disturbi Comportamentali” (Area of Behavioral and Psychological Symptoms)), ADL (Activities of Daily Living), AEP (Appropriateness Evaluation Protocol), BRASS (Blaylock Risk Assessment Screening Score), CI (Confidence Interval), CIRS (Cumulative Illness Rating Scale), CIRS-CI (Cumulative Illness Rating Scale – Comorbidity Index), CIRS-SI (Cumulative Illness Rating Scale – Severity Index), ED (Emergency Department), GP (General Practitioner), IADL (Instrumental Activities Daily Living), ICD-9-CM (International Classification of Diseases Ninth Revision Clinical Modification), LOS (Length of Stay), OR (Odds Ratio), PPS (Palliative Performance Scale)
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