Abstract
BackgroundRising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes.MethodsRetrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay.ResultsIncidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05).ConclusionsR-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.
Highlights
Rising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally
In the UK, the recent increases observed in unplanned hospital admissions of older people have been described as unsustainable for the National Health Service (NHS) [1,2]
Admissions for ill-defined conditions (R-codes) are coded with an R prefix within Chapter XVIII of the International Classification of Diseases (ICD)-10 (’Symptoms, signs and abnormal laboratory findings’), equivalent to codes 7800 to 7990 in Chapter XIV (’Symptoms, signs and illdefined conditions’) of the ICD-9, from which the term ill-defined conditions has remained in use
Summary
Rising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. Unplanned hospital admissions for ill-defined conditions are known to be increasing in the UK and other countries and they are a common feature of older people’s admissions, demonstrating a stepwise increase in incidence with age even within older populations [9,10,11,12,13,14,15]. Ill-defined conditions admissions have been highlighted as a target for admission reduction strategies under the assumption that they are a consequence of increased prevalence of inadequately managed chronic disease in the ageing population and because they may be avoidable through improved chronic disease management in the community [6,17]. Analysis of national data suggests that health service organisational factors, such as access to alternative services and changes to admission procedures may be more important than ageing and chronic disease [11,18]
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