The cost of social isolation in older people in the English and Portuguese National Health Services

In this thesis I explore the impact of social isolation on delayed hospital discharges of older proximal femoral fracture (PFF) patients in Portugal and in England, and estimate the costs associated with these delays. A delayed discharge occurs when a patient remains in hospital after being deemed medically fit for discharge, and a better understanding of them will help when designing policies to reduce them and improve the allocation of scarce healthcare resources. Although the literature reports that delayed hospital discharges are prevalent and costly, I found limited knowledge about the impact of pre-admission patient characteristics, including social isolation, on these delays; the significant variability in prevalence of delayed discharges, which could be better understood if estimated by disease area; and the costs associated with such delays. To address these knowledge gaps, I assessed the impact of social isolation, measured with a validated tool, on delayed hospital discharges in older patients using two case studies: PFF patients admitted to the Hospital de Santa Maria (HSM) in Portugal and to the John Radcliffe Hospital (JRH) in England. My research showed that social isolation is a predictor of the number of days of delayed hospital discharges. However, whereas in Portugal the number of days of delayed discharges increased progressively with the level of social isolation, in England no such dose-response relationship was observed, indicating that any social isolation leads to delayed discharge but the level of social isolation has little effect. The costs of delayed discharges were found to be significant in both countries. Preventing delayed discharges could have led to a €2,352 saving in hotel costs per PFF patient with a delay in discharge in Portugal, and £2,328 in England. When extrapolated to a national level, the annual costs of delayed discharges were estimated to vary between 5.4% and 11.2% of total acute inpatient costs for PFF patients aged 75 and above in Portugal, and between 2.9% and 4.4% of total acute inpatient costs for PFF patients aged 70 and above in England. Two interventions aiming at alleviating social isolation were identified through a systematic review and were incorporate in the delayed discharge models at the HSM and the JRH. The case studies show potential for these interventions to reduce the number of days of delayed discharge.