BMJ  2004;328:1288 (29 May), doi:10.1136/bmj.38072.481933.EE (published 16 April 2004)

Paper

Hospital admissions, age, and death: retrospective cohort study

¹ Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Abstract

Objectives Ageing of the population brings the possibility of increased burdens for acute hospital services because of the marked increase in many common diseases with age. We aimed to examine the relation between age and use of acute services in hospitals in the period before death in a national sample of deaths in hospital.

Design Retrospective cohort analysis of English hospital episode statistics database.

Setting All NHS hospitals in England.

Data set All post-neonatal deaths occurring in English NHS hospitals during financial year 1999-2000, with episodes of care in the previous three years determined through matching on sex, date of birth, and postcode.

Main outcome measures Total bed days, mean and median length of stay.

Results 253 799 in-hospital deaths were identified, representing about 45% of all deaths occurring in 1999-2000. Patients who died in hospital spent a median of 23 days in hospital in the three years before death; the median rose with age up to 45 years, but was fairly stable for ages 45 and above. The number of admissions to NHS hospitals in the three years before death averaged 3.6; this peaked at 10.4 in patients aged 5-9 years and decreased with age to 2.2 in those aged 85 and over.

Conclusions The average number of bed days spent in hospital in the period before death does not increase with increasing age.

Introduction

With life expectancy continually increasing in most countries, population ageing has become an important issue worldwide. This has led to concerns about the impact this will have on healthcare systems, given the marked increase in many diseases with age. Public debate over the perceived overuse of health care services by older people has included discussions of equity, the "fair innings" argument, and age based rationing of health care.

One view is that the increasing numbers of older people will inevitably result in a greater burden of chronic and degenerative diseases, such as cardiovascular diseases, osteoarthritis, cancers, diabetes, cataract and macular degeneration, and dementia syndromes, which will result in an increased demand for health care and hence soaring costs.^{1 2} An alternative suggestion is that the increase in total life expectancy has been accompanied by an increase in healthy life expectancy, due to a compression of morbidity into a shorter period, effectively postponing the onset of chronic diseases and associated disabilities.^{1 3 4} This second scenario would result in a lower burden on healthcare resources than the first.⁵

A key concern in this debate has been the utilisation and cost of acute care. In his interim report on estimating the resources required to run the English health service in 2020, Wanless stated: "Age and people's proximity to death are the most significant determinants of health status and health needs, but the impact of ageing on future expenditure is likely to be relatively small when compared to other cost drivers."⁶ In the acute setting, to what extent does age, rather than proximity to death, lead to higher costs? This paper examines that question by considering the acute phase of care provided by the public sector. We asked: does the total time spent in hospital or the number of spells in hospital, or both, in the three years before death vary with age?

Methods

We analysed hospital episode statistics for England. The database (www.dh.gov.uk/PublicationsAndStatistics/Statistics/HospitalEpisodeStatistics/fs/en) holds information on patients who are admitted, either as a day case or as an ordinary admission, to NHS hospitals in England. Private hospital procedures are excluded from the database.

We identified all episodes (excluding births) for the data year 1999-2000 (1 April 1999 to 31 March 2000) which resulted in the patient's death. Deaths were matched on date of birth, postcode, and sex to the records of all general episodes to identify all episodes of acute care provided in the three financial years before death (1996-7 to 1998-9) to patients who died in hospital in the financial year 1999-2000.

For each patient we calculated the total number of days spent in hospital and the number of separate admissions in the year, two years, and three years before death.

Results

Record matching identified 253 779 deaths in NHS hospitals between 1 April 1999 and 31 March 2000. Of these, 216 341 (85.3%) were in patients aged 65 years or over and 72 579 (28.6%) in patients aged 85 years or over (see table 1 on bmj.com). Nearly two thirds (64.5%) of those aged 85 or over were female. The average age at death was 74.2 years for males and 78.0 years for females. Diagnoses varied by age (see table 2 on bmj.com).

Time spent in hospital
Patients who died in hospital in 1999 spent a median of 23 days in hospital in the three years before death (table). Much of this time was accumulated during the year immediately before death (median 18 days in hospital). Time spent in hospital ranged from the day of death only to the entire three-year period; however, 60% of all patients who died in hospital spent less than one month in hospital over the three years before death, and only 5% spent more than four months of their final three years in hospital. This does not include time spent in a hospice, nursing home, or residential care. The median number of days spent in hospital rose with age up to 45 years, but was fairly stable for ages 45 and above. The patterns for the amount spent in hospital in the one, two, and three years before death were broadly similar.

View this table: [in this window] [in a new window]   Deaths in hospital, 1 April 1999 to 31 March 2000, England

 

The groups of diagnoses at death associated with the most hospital days over three years were mental and behavioural disorders (median 59 days), use of other health services (for example, cancer treatment, palliative or respite care, or rehabilitation after a stroke; median 54 days), and diseases of the nervous system (median 33 days).

Number of admissions
Patients who died in hospital had on average 3.6 admissions to NHS hospitals in the three years before death. The average number of admissions peaked at 10.4 in the 5-9 years age group and then decreased with age to 2.2 in patients aged 85 and over (figure). The maximum number of admissions was 441. Of patients who died in hospital, 78% had four or fewer admissions, and only 5% had more than 10 admissions over the three years. A very small proportion of patients (0.03%; 78 patients) were admitted to hospital more than 100 times in the three years before their death; 37 (47%) of these were receiving cancer treatment, 21 (27%) were having dialysis, and 13 (17%) had diseases requiring regular blood transfusions.

View larger version (21K): [in this window] [in a new window]   Number of admissions to hospitals in the three years before death, England, 1999-2000. Lines represent medians, boxes represent interquartile ranges, whiskers represent 1.5 times the interquartile range

 

Discussion

Deaths below the age of 65 and above the age of 85 years accounted for about 15% and 29% respectively of the nearly 254 000 in-hospital deaths occurring in 1999-2000. Neither total hospital days nor the number of admissions in the three years before death showed the expected positive relation to age at death. Although the median number of days in hospital in the three years before death increased up to age 45, it remained fairly stable after this age. The number of admissions in the three years before death decreased after age 25-44.

Also other studies using the Oxford record linkage data^{7 8} provide further counterpoint to the "pervasive image" described by Cohen of "an extremely elderly and terminally ill patient consuming large amounts of resources shortly before he or she dies" through the use of expensive technology and treatments, multiple admissions, and long lengths of stay.⁹ Our sample of patients who died in hospital showed no increase in median total bed days or number of admissions after the age of 45 years, and in fact the group most likely to have had multiple admissions was children. While as a whole the older age groups account for a larger total number of admissions and bed days in the three years before death, this is due to the fact that as age increases, a higher proportion of people are in the final stages of their lives.

Limitations
Our study included only people who died in hospital. At all ages, 50-55% of deaths each year occur in NHS hospitals.¹⁰

Secondly, the use of hospital bed days as a proxy for use of hospital costs assumes that patients of all ages and diagnoses consume the same amount of resources per bed day. This is obviously not the case: while fixed costs such as food, maintenance, and nursing salaries should be standard, different treatments and regimens of care will have different costs. The care of older people is unlikely to be more expensive: despite their greater likelihood of comorbidity and the need for a longer recuperation period (reflected in bed days), they are much less likely to receive intensive care or undergo surgery or complex interventions.

Conclusions
The average number of bed days spent in hospital in the period before death shows no discernable increase with increasing age. These findings concur with previous studies that have shown that the highest proportion of costs for acute care are incurred in the final years of life, no matter at what age this happens to be, and that total costs of acute care are greater in elderly people simply because this age group makes up a larger proportion of dying people.^11-13 Such findings have important implications for understanding the use of acute hospital resources and for distinguishing the costs of dying from the costs of ageing.

What is already known on this topic Population ageing brings with it the possibility of increased burden on acute hospital services because of the increase in many common diseases with age Although average costs for acute care increase with age, these costs are related to life remaining rather than life lived What this study adds Among patients who died acute services because in NHS hospitals, use of did not increase with age in the three years before death The number of admissions over this period decreased with age, and average length of stay was stable above age 45 years The older sector of the population accounts for a high proportion of because they are nearing care is acute health care resources the end of their lives, not individually more expensive

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This is the abridged version of an article that was posted on bmj.com on 16 April 2004: http://bmj.com/cgi/doi/10.1136/bmj.38072.481933.EE Hospital episodes statistics (HES) data were made available by the Department of Health.

Contributors: See bmj.com

Funding: The Medical Research Council (UK). MS is funded by the South West Public Health Observatory. HES analyses conducted within the Department of Social Medicine are supported by the South West Public Health Observatory.

Competing interests: None declared.

Ethical approval: None required.

References

1. Brameld KJ, Holman CDJ, Bass AJ, Codde JP, Rouse IL. Hospitalisation of the elderly during the last year of life: an application of record linkage in Western Australia 1985-1994. J Epidemiol Community Health 1998;52: 740-4.[Abstract]
2. Guralnik JM, Land KC, Blazer D, Fillenbaum GG, Branch LG. Educational status and active life expectancy among older blacks and whites. N Engl J Med 1993;329: 110-6.[Abstract/Free Full Text]
3. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med 1980;303: 130-5.[Abstract]
4. Manton KG, Corder L, Stallard E. Chronic disability trends in elderly United States populations: 1982-1994. Proc Natl Acad Sci USA 1997;94: 2593-8.[Abstract/Free Full Text]
5. Maynard A, Sheldon T, Loudon I, Webster C, Rao JN, Frankel S, et al. Limits to demand for health care. BMJ 2001;322: 734.[Free Full Text]
6. Wanless D. Securing our future health: taking a long-term view. Interim report. London: HM Treasury, 2001.
7. Henderson J, Goldacre MJ, Griffith M. Hospital care for the elderly in the final year of life: a population based study. BMJ 1990;301: 17-9.
8. Himsworth RL, Goldacre MJ. Does time spent in hospital in the final 15 years of life increase with age at death? A population based study. BMJ 1999;319: 1338-9.[Free Full Text]
9. Cohen GD. Health care at an advanced age. Myths and misconceptions. Ann Intern Med 1994;121: 146-7.[Free Full Text]
10. Office for National Statistics. Mortality statistics: general. London: ONS, 2000. (Series DH1 No 33.)
11. McGrail K, Green B, Barer ML, Evans RG, Hertzman C, Normand C. Age, costs of acute and long-term care and proximity to death: evidence for 1987-88 and 1994-95 in British Columbia. Age Ageing 2000;29: 249-53.[Abstract/Free Full Text]
12. Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999;8: 485-96.[CrossRef][Web of Science][Medline]
13. Busse R, Krauth C, Schwartz FW. Use of acute hospital beds does not increase as the population ages: results from a seven year cohort study in Germany. J Epidemiol Community Health 2002;56: 289-93.[Abstract/Free Full Text]

(Accepted 18 March 2004)

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