What is inappropriate hospital use for elderly people near the end of life? : a systematic review

Background: Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate. Aim: To investigate extent and causes of inappropriate hospital admission among older patients near the end of life. Methods: English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995–December 2016) covering community and nursing home residents aged ≥ 60 years admitted to hospital. Outcomes: measurements of inappropriateness. A 17-item quality score was estimated independently by two authors. Results: The definition of ‘Inappropriate admissions’ near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7–67.0%); family requests (up to 10.5%); or too late an admission to be of benefit (1.7–35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness. Conclusions: Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake