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.