The role of intervening hospital admissions on trajectories of disability in the last year of life: prospective cohort study of older peopleBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2361 (Published 20 May 2015) Cite this as: BMJ 2015;350:h2361
- Thomas M Gill, professor of medicine12,
- Evelyne A Gahbauer, data manager1,
- Ling Han, senior research scientist1,
- Heather G Allore, associate professor of medicine1
- 1Yale School of Medicine, Department of Internal Medicine, New Haven, CT, USA
- 2Adler Geriatric Center, New Haven, CT 06510, USA
- Correspondence to: T M Gill
- Accepted 18 March 2015
Objective To evaluate the role of intervening hospital admissions on trajectories of disability in the last year of life.
Design Prospective cohort study.
Setting Greater New Haven, Connecticut, United States, from March 1998 to June 2013.
Participants 552 decedents from a cohort of 754 community living people, aged 70 years or older, who were initially non-disabled in four essential activities of daily living: bathing, dressing, walking, and transferring.
Main outcome measure Occurrence of admissions to hospital and severity of disability (range 0-4), ascertained during monthly interviews for more than 15 years.
Results In the last year of life, six distinct trajectories of disability were identified, from least disabled to most disabled: 95 participants (17.2%) had no disability, 61 (11.1%) had catastrophic disability, 53 (9.6%) had accelerated disability, 61 (11.1%) had progressively mild disability, 127 (23.0%) had progressively severe disability, and 155 (28.1%) had persistently severe disability. 392 (71.0%) participants had at least one hospital admission and 248 (44.9%) had multiple hospital admissions. For each trajectory the course of disability closely tracked the monthly prevalence of hospital admission. In a set of multivariable models that included several potential confounders, hospital admission in a given month had a strong independent effect on the severity of disability, in both relative and absolute terms. The largest absolute effect was observed for catastrophic disability, with a mean increase in disability score of 1.9 (95% confidence interval 1.5 to 2.4) in the setting of a hospital admission, corresponding to a rate ratio (or relative effect) of 2.0 (95% confidence interval 1.5 to 2.7).
Conclusions In the last year of life, acute hospital admissions play an important role in the disabling process. Knowledge about the course of disability before these intervening events may facilitate clinical decision making at the end of life. For older patients admitted to hospital with progressive or persistent levels of severe disability, representing more than half of the decedents, clinicians might consider a palliative care approach to facilitate discussions about advance care planning and to better deal with personal care needs.
We thank Denise Shepard, Andrea Benjamin, Barbara Foster, and Amy Shelton for assistance with data collection; Wanda Carr and Geraldine Hawthorne for assistance with data entry and management; Linda Leo-Summers for assistance with the figures; Peter Charpentier for design and development of the study database and participant tracking system; Joanne McGloin for leadership and advice as the project director; and our participants for sharing information about their health and function over the past 17 years.
Contributors: LH conducted the statistical analyses under the supervision of HGA. All authors participated in designing the analyses, interpreting the results, and writing the manuscript. All authors had full access to the data and are guarantors for the study.
Funding: This study was supported by grants from the National Institute on Aging (R37AG17560, R01AG022993). The study was conducted at the Yale Claude D Pepper Older Americans Independence Center (P30AG21342). TMG is the recipient of an academic leadership award (K07AG043587) from the National Institute on Aging. The funders had no role in the conduct of the research.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: This study was approved by the Human Investigation Committee at Yale School of Medicine; each participant provided informed consent.
Data sharing: No additional data available.
Transparency: The lead author (TMG) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.
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