Laporan Review Jurnal Skill Lab 1

( Deskkritif & Analitik )

Oleh
Andery Intan Martalia
NPM : 14310014
Kelompok 2

PROGRAM STUDI PENDIDIKAN KEDOKTERAN

FAKULTAS KEDOKTERAN
UNIVERSITAS MALAHAYATI
2017
 DAFTAR ISI

A. Reviw Jurnal Deskriptif

Prevalensi gejala dispepsia dan
Heartburn pada orang dewasa di Belo Horizonte, Brasil

B. Reviw Jurnal Deskriptif

Hubungan antara lokasi di rumah sakit dan hasil perawatan pada pasien yang didiagnosis
dengan diagnosis demensia dan / atau delirium: analisis perjalanan pasien
1. Review Jurnal Deskriptif

A. Judul Jurnal
Arq Gastroenterol. 2017 Jan-Mar;54(1):46-50. doi: 10.1590/S0004-
2803.2017v54n1-09.
Prevalence of dyspeptic symptoms and heartburn of adults in Belo
Horizonte, Brazil.
Almeida AM1, Martins LA2, Cunha PL2, Brasil VW2, Flix LG2,
Passos MD1.

B. Latar Belakang Teori

Literatur medis telah menunjukkan gejala dispepsia dan gejala
terkait terjadi di antara 15% sampai 40% populasi. Gejala ini bisa
terjadi pada usia heartburn berapapun dan lebih banyak terjadi pada
wanita.

C. Masalah Penelitian

D. Tujuan Penelitian
Mencari prevalensi gejala dispepsia dan sakit maag di antara
individu berusia di atas 18 tahun

E. Metodologi Penelitian
Random sampling

F. Hasil Penelitian: Sebanyak 548 individu diwawancarai. Di

antaranya, 58,4% adalah perempuan, 59,3% berkulit putih, 55,9%
single dan usia rata-rata 36 tahun. Dalam kelompok ini, 376
individu (68,6%) menyatakan memiliki beberapa gejala dan / atau
menggunakan obat untuk menghilangkan gejala dispepsia, dan
untuk pasien ini diaplikasikan kuesioner Roma III. Berdasarkan
kriteria diagnostik untuk kuesioner yang diajukan oleh konsensus
Roma III, gejala kepenuhan postprandial dilaporkan oleh 6,7%
individu, rasa kenyang awal (3,5%) dan nyeri epigastrik (10,6%).
Tumpang tindih gejala ini sangat sering terjadi. Prevalensi
dispepsia fungsional adalah 10,6% (sindrom ketidaknyamanan
postprandial (8,2%) dan sindrom nyeri epigastrik (2,4%). Di antara
semua peserta, 52,5% melaporkan sakit maag, dan 11,1%
menunjukkan gejala ini paling sedikit sekali seminggu. Obat yang
paling sering digunakan adalah omeprazol.
 G. Kesimpulan
Prevalensi gejala dispepsia dan heartburn di antara populasi
perkotaan orang dewasa Brasil serupa dengan yang dijelaskan di
negara lain.

2. Review Jurnal Analitik

A. Judul Jurnal
BMC Geriatr. 2016 Nov 24;16(1):190.
The relationship between in-hospital location and outcomes of care
in patients diagnosed with dementia and/or delirium diagnoses:
analysis of patient journey.
Perimal-Lewis L1,2, Bradley C3,4, Hakendorf PH5, Whitehead C5,4,
Heuzenroeder L6,4, Crotty M5,4.

B. Latar Belakang Teori

Perbedaan antara jumlah penerimaan dan alokasi tempat

tidur rumah sakit berarti bahwa banyak pasien yang dirawat di

rumah sakit dapat ditempatkan di unit atau bangsal selain yang

mengkhususkan diri pada masalah kesehatan primer pasien (home-

ward). Pasien ini disebut pasien 'outlier'. Faktor risiko dan hasil

sistem kesehatan dari perawatan di rumah sakit untuk pasien

'outlier' yang didiagnosis dengan demensia dan / atau delirium

tidak diketahui.

C. Masalah Penelitian

D. Tujuan Penelitian
 untuk memeriksa perjalanan pasien penderita demensia dan

/ atau diagnosis delirium, untuk mengidentifikasi faktor risiko

status 'inlier' atau 'outlier' dan hasil atau konsekuensi sistem

kesehatan atau pasien (status).

E. Metodologi Penelitian
deskriptif retrospektif

F. Hasil Penelitian : pada 6367 rawat inap dengan demensia dan /

atau delirium di dalam FMC diperiksa, LOS) setelah dirawat

sebagai pasien rawat inap berkepanjangan untuk pasien 'outlier'

dibandingkan pasien 'inlier' (OR: 1.068, 95% CI: 1.057-1.079, p =

0.000). Namun, pasien rawat jalan LOS untuk pasien 'saja' hanya

sedikit lebih pendek dari pada pasien 'inlier' (OR: 0,998, 95% CI:

0,998-0,998, p = 0,000). Kemungkinan kematian dalam 48 jam

penerimaan meningkat untuk pasien 'outlier' (OR: 1.973, 95% CI:

1.158-3.359, p = 0,012) dan Indeks morbiditas Charlson mereka

lebih tinggi (OR: 1,059, 95% CI: 1,021-1,10, p = 0,002).

G. Kesimpulan

bahwa hasil sistem kesehatan untuk pasien dengan demensia dan /

atau delirium yang dirawat di luar rumah mereka dipengaruhi oleh lokasi

di rumah sakit meskipun memiliki populasi homogen dari populasi

penelitian.
DESKRITIF
Prevalence of dyspeptic symptoms and heartburn of adults in Belo Horizonte,
Brazil

ABSTRACT

BACKGROUND

Medical literature has shown dyspepsia and heartburn-related symptoms occur

among 15% to 40% of the population. These symptoms can occur at any age and
are more prevalent in women.

OBJECTIVE

Investigate the prevalence of dyspeptic symptoms and heartburn among

individuals over 18.

METHODS

Individuals over 18 were randomly selected in public venues in Belo

Horizonte/MG to participate. A standardized questionnaire that included
questions related to social-demographic characteristics, eating habits, digestive
symptoms, medical appointments, medications, exams, previous surgeries and
comorbidities was applied. A questionnaire about functional dyspepsia diagnosis
(Rome III) was also applied.

RESULTS

A total of 548 individuals were interviewed. Among these, 58.4% were women,
59.3% were white, 55.9% were single and the average age was 36 years. Within
this group, 376 individuals (68.6%) declared to have some symptom and/or use
medication to relieve dyspepsia symptoms, and for these patients were applied
the Rome III questionnaire. Based on the diagnostic criteria for the
questionnaire proposed by the Rome III consensus, the symptom of postprandial
fullness was reported by 6.7% of the individuals, early satiety (3.5%) and
epigastric pain (10.6%). The overlap of these symptoms was very frequent. The
prevalence of functional dyspepsia was 10.6% (postprandial discomfort syndrome
(8.2%) and epigastric pain syndrome (2.4%). Among all participants, 52.5%
reported heartburn, and 11.1% presented this symptom at least once a week. The
most used drug was omeprazole.

CONCLUSION

The prevalence of dyspeptic symptoms and heartburn among a Brazilian adult

urban population is similar to those described in other countries.

Headings: Dyspepsia; diagnosis; Heartburn; Consenso

RESUMO

CONTEXTO

Tem sido relatado que cerca de 15% a 40% da populao geral apresenta alguma
queixa dispptica e/ou pirose. Os sintomas disppticos podem surgir em qualquer
idade e so mais prevalentes no sexo feminino.

OBJETIVO

Investigar a prevalncia de sintomas disppticos e pirose em indivduos com

idade superior a 18 anos.

MTODOS

Foram selecionados aleatoriamente indivduos com idade superior a 18 anos,

entrevistados em praas pblicas de Belo Horizonte/MG, por meio de um
questionrio que abordou caractersticas scio-demogrficas, questes
relacionadas aos hbitos alimentares, sintomas digestivos, consultas mdicas,
medicamentos, exames, antecedentes cirrgicos, comorbidades e questionrio
especfico para diagnstico de dispepsia funcional (Roma III).

RESULTADOS

Foram entrevistados 548 participantes. Destes, 58,4% eram mulheres, 59,3% da

raa branca, 56% solteiros e a idade mdia foi de 36 anos. Neste grupo, 376
indivduos (68,6%) declararam ter algum sintoma e/ou utilizar algum
medicamento para aliviar sintomas disppticos. Para esses indivduos, foi
utilizado o questionrio Roma III para o diagnstico de dispepsia sendo sintoma
de plenitude ps-prandial (6,7%), saciedade precoce (3,5%) e a dor ou queimao
no estmago (azia) presente em 10,6%. A sobreposio desses sintomas foi muito
frequente. A prevalncia de dispepsia funcional foi de 10,6% (sndrome de
desconforto ps-prandial (8,2%), sndrome da dor epigstrica (2,4%)). Dentre os
participantes, 52,5% relatavam pirose, sendo que desses 11,1% apresentavam
este sintoma, no mnimo, uma vez por semana. O medicamento mais utilizado foi
o Omeprazol.

CONCLUSO

A prevalncia dos sintomas disppticos e pirose na populao urbana adulta

brasileira semelhante a descrita em outros pases.

Descritores: Dispepsia; diagnostic; Azia; Consensus

INTRODUCTION

The Dyspeptic syndrome is defined by the presence of persistent or

recurring pain and/or discomfort, located in the central and upper (epigastrium)
abdomen These symptoms may result from different diseases such as peptic
ulcer, gastric cancer and, most importantly, functional dyspepsia (FD).

These dyspeptic symptoms may also be related to intestinal parasitosis,

such as Giardiasis and strongyloidiasis, and in Brazil this may be important for
a differential diagnosis.

It affects 25% to 40% of the adults in Western populations (higher

prevalence are described in studies that also included heartburn, which is
considered a characteristic symptom of the gastroesophageal reflux disease).
Dyspeptic complaints are responsible for 2% to 5% of outpatient visits in general
practitioners, in a primary care center, and 20% to 40% of gastroenterology
appointments, and represent a great impact on the quality of life of patients.
Dyspepsia is classified as an organic disease (when is secondary to specific
lesions, such as esophagitis, peptic ulcer or gastric cancer) or FD (in the absence
of structural abnormalities or metabolic and biochemical irregularities that
justify the symptoms)

An international committee of experts established, in recent years, specific

criteria for dyspepsia diagnosis and classification (Rome Criteria), progressing
towards the understanding of the syndrom .The Rome consensus suggests the
use of specific questionnaires for FD diagnosis, with a validated version for the
local language which can be used in the diagnostic investigation, by the assistant
doctor, or for basic research purposes, but it stresses that physical examination
and complementary exams are fundamental to confirm a diagnosis.
 According to Rome III consensus, the following criteria is required for the
diagnosis of FD: 1) dyspeptic complaints during the last three months and that
started at least 6 months before; 2) presence of one or more of the following
symptoms: postprandial fullness, early satiety; epigastric pain; epigastric
burning; absence of structural lesions in the upper digestive endoscopy.

For better clinical and therapy guidance, patients with FD should be

classified, according to their main symptom, in two syndromes : a) Post-Prandial
Distress Syndrome (predominant symptoms are postprandial fullness and/or
early satiety, which occurs several times per week in the last 3 months) and/or;
b) epigastric pain syndrome (predominant symptoms are epigastric pain or
epigastric burning sensation, which is moderate to intense, intermittent, and
that occurs at least once a week in the last 3 months).

Population-based studies on this particular topic are rare and, in general,

have methodological problems considering the difficulty to exclude structural
diseases in a large sample, as required for population studies. Another factor is
that the diagnostic criteria for dyspepsia is not standard, although most authors
use the criteria suggested by the Rome consensus

A population-based study carried out in southern Brazil showed a

prevalence of 44% of dyspeptic complaints, when using the Rome I criteria and
19.5% with the Rome II criteria. Dyspeptic symptoms may appear at any age and
are more frequent among women, probably due to the fact that the female
population seeks medical help quicker. The intensity of pain and/or discomfort,
and anxiety (including the fear of more serious diseases), are the main reasons
for seeking a clinical or gastroenterologist opinion.

Heartburn and acid regurgitation symptoms are also common in the

Gastroesophageal Reflux Disease (GERD), and are very frequent in daily clinical
practice. The prevalence of GERD is quite variable among the population but is
usually high.

The objective of this study is to investigate the prevalence of dyspeptic symptoms

and heartburn among individuals older than 18 in a Brazilian urban population.

METHODS

Six hundred individuals over 18 were randomly selected in public places within
the city of Belo Horizonte/MG, who were invited to participate in the study, and
consented their participation according to ethical documentation standards. The
individuals answered a questionnaire that included social-demographic
characteristics, eating habits, digestive symptoms, medical appointments,
medications, exams, previous surgeries and comorbidities. A specific
questionnaire for FD diagnosis (Rome III) was applied only among individuals
reporting upper digestive tract complaints in the last six months (pain or
burning sensation in the chest, pain or burning in the stomach, acid
regurgitation, nausea, vomiting, eructation and abdominal fullness) and those
who used medication for symptom relief in the last six months.

The Rome III questionnaire is a standardized and trustworthy instrument with a

validated version for Brazilian Portuguese

Eighteen items with ordinal scale responses and individual frequency limits are
part of the Rome III questionnaire for dyspepsia. Items 3, 5 and 7 are questions
about the frequency of postprandial fullness, early satiety, and epigastric pain or
burning sensation symptoms in the last 3 months. Items 4, 6 and 8 shall
determine beginning of the symptoms for 6 months or longer with dichotomous
responses (yes/no). Items 3 and 5 relate to the diagnosis of postprandial
discomfort syndrome (PDS) and items 1, 2, 7, 9, 10 and 12 characterize the
epigastric pain syndrome (EPS). Items 11 to 18 show have questions that exclude
functional gallbladder and sphincter of Oddi disorder possibilities.

For dyspepsia diagnosis, the proposed scheme drawn up by experts and

determined by the consensus considering the Rome III questionnaire items, is: I),
postprandial fullness: question 3>4, question 4=1; II) early satiety: question 5>4,
question 6=1; III) epigastric pain: question 7>3, question 8=1; IV) postprandial
discomfort syndrome (PDS): question 3>4, question 4=1, question 5>4, question
6=1. This syndrome includes the symptoms of postprandial fullness and early
satiety; V) of epigastric pain syndrome (EPS): question 1<3, question 2<3,
question 7>3, question 8=1, question 9>1, question 10>2, question 12=0. This
syndrome includes the symptoms of epigastric pain or burning.

The descriptive analysis conducted included distributions of frequencies, central

tendency measures and the variability of the characteristics evaluated. The
software used for statistical analyses was SPSS(r) version 19.0. A 5% significance
level was considered for all analyses.

The project was approved by the Research Ethics Committee with a presentation
ethical assessment certificate (CAAE) number: 04875712.0.0000.5134.

RESULTS

Among 600 participants invited to participate in the study, 548 (91.33%)

accepted to participate and 52 (8.66%) were excluded for not agreeing to sign the
consent form. Among 548 patients, 320 (58.4%) were women, 325 (59.3%) were
white, 307 (56%) were single and 85.6% considered their health condition
good/very good. Concerning the educational level of the participants, an average
13.20 years in school (3.91) was considered as well as an average age of 36
(16.13) years.

Among these, 376 (68.6%) presented some digestive symptom and/or are using
medication for symptom relief. Therefore, for these individuals, the Rome III
symptom questionnaire was applied. In this group, 232 (61.7%) were women, 226
(60.1%) were white, 213 (56.6%) were single and 83% considered their health
condition good/very good. Concerning the educational level of the participants, an
average 13.2 years in school (3.90) was considered as well as an average age of
35 years (15.90)

TABLE 1 Characteristics of 376 individuals interviewed

n % Average (SD)
Gender
Male 144 38.3
Female 232 61.7
Skin color
Black 27 7.2
Brown 97 25.8
White 226 60.1
Other 26 7.0
Marital status
Single 213 56.6
Married 120 31.9
Separated 10 2.7
Divorced 20 5.3
Widowed 05 1.3
Other 08 2.1
Age 35.2 years (15.90)
Years of study 13.24 years (3.90)
Total 376 100

SD: standard deviation

The diagnosis criteria in the Rome III questionnaire was used, and the
postprandial fullness symptom was reported by 25 individuals (6.7%), early
satiety by 13 (3.5%) and epigastric pain by 40 (10.6%). Eight (2.1%) participants
reported only postprandial fullness; 24 (6.4%) only complained about epigastric
pain and 4 (1.2%) mentioned early satiety. Figure 1 shows the frequent overlap
of these symptoms among the symptomatic population.
FIGURE 1 Prevalence of postprandial fullness (PPF) symptoms, early satiety
(ES) and epigastric pain (EP) with a sample of 376 individuals interviewed in
public venues in the city of Belo Horizonte/MG.

By adopting the criteria proposed by the Rome consensus, the prevalence of

functional dyspepsia was 10.6%, and 31 (8.2%) participants fulfilled the criteria
for the diagnosis of postprandial discomfort syndrome (PDS) (early satiety and/or
postprandial fullness) and 9 (2.4%) fulfilled the criteria for epigastric pain
syndrome (EPS). There was also a frequent overlap of dyspepsia symptoms
observed.

Regarding to the occurrence of heartburn, 40 participants (11.1%) stated that felt

it at least once a week, 26 (7.2%) at least twice a week and only two (0.5%) stated
that felt discomfort everyday

TABLE 2 Heartburn (discomfort or burning in the chest) occurrence in the last 3

months

Options N % Valid % Cumulative frequency

0 never 170 47.2 47.2
1 -less than once a month 63 17.5 64.7
2 - once a month 41 11.4 76.1
3 - 2-3 days a month 46 12.8 88.9
4 - once a week 14 3.9 92.8
5 -more than once a week 24 6.7 99.5
6 - everyday 02 0.5 100.0
Total 360 100.0 -
Heartburn or epigastric pain were the most common symptoms, with moderate
intensity mostly, that disappeared on the same day and were relieved with
medication. Evacuation and changing body positions relieved approximately 50%
of individuals. These symptoms were frequently followed by nausea, an
uncomfortably "full" feeling after a normal size meal and early satiety.

Life Habits changes (avoid bulky and/or fatty meals, cut off foods containing
caffeine or similar, cut down alcohol consumption and the number of cigarettes)
in the last 6 months could be observed in both groups, symptomatic and
asymptomatic. However, the majority of these changes occurred in the
symptomatic group. In this group, 35.4% mentioned they reduced large and/or
bulky and/or fatty meals, 23.1% became moderate alcohol consumers and 27.7%
reduced their caffeine intake. The majority of patients were non-smokers (76.5%)
and among the symptomatic group (64.7%) of the patients who smoke have
reported necessity to cut down the number of cigarettes.

The most used medication was omeprazole (39.6%), followed by pantoprazole

(9.3%) and antacids (4.8%).

DISCUSSION

In this study, 68.6% of the participants presented symptoms and/or have been
using symptom relief medication in the last 6 months. In this group, a higher
prevalence of women was observed, which was also described by other studies
Higher FD and heartburn prevalence has been observed among women, however,
the same finding is not reported for gastroesophageal reflux disease.

By adopting the criteria suggested in the Rome III consensus, we observed that
the prevalence of FD was 10.6%, and 8.2% met the criteria for the diagnosis of
postprandial discomfort syndrome (PDS) (early satiety and/or postprandial
fullness) and 2.4% for epigastric pain syndrome (EPS). When evaluating the
symptoms independently, postprandial fullness was reported by 6.7%, early
satiety by 3.5% and epigastric pain by 10%. A frequent overlap of the dyspeptic
symptoms was observed. In this study, 52.8% reported heartburn, and more
than18% have it at least once a week.

According to studies in the United States, Norway, England and other European
countries, the prevalence of FD varies between 20% and 40% of the population,
with an annual incidence of 1% to 8%. This variation can be related to
geographical differences and the different criteria used to diagnose the disease.

An epidemiological study of adults in Great Britain has demonstrated a 40%

dyspepsia prevalence. More than half of these individuals were using medication,
and 22% of them underwent medical visits in the year prior to the study.
A study conducted in the United States indicated a 31.9% dyspepsia prevalence.
However, when heartburn cases were excluded (Rome I and II criteria), the
prevalence dropped to 15.8%. The most frequent cause of dyspepsia was
functional.

In a study carried out in the Czech Republic, 17% prevalence of gastrointestinal

symptoms was registered among the general population, and the prevalence of
FD was higher among women, similar results have been observed in our study.

In Brazil, a study conducted in the southern region, interviewed 3934

individuals, at home, using the Rome II criteria. Frequent dyspepsia was
classified as individuals with dyspeptic episodes more than six times per year.
The prevalence of dyspepsia was 44.4% and frequent dyspepsia was 27.4%.
Among women, dyspepsia was more frequent. When excluding patients with
heartburn more than once a week, the prevalence of dyspepsia dropped to 15.9%
and frequent dyspepsia to 7.5%

However, studies performed in the Western world using the Rome III criteria
demonstrated that the prevalence of FD lies between 9.8 and 20.2%, which
matches the data obtained in this study.

Another study conducted in northern Sweden indicated a 15.7% prevalence of

FDThe PDS was present in 12.2%, EPS in 5.2% and the overlap of two
syndromes was only observed among 1.7% of the population investigated.
Finally, a population survey carried out in the region of Minnesota, USA, showed
a 15% prevalence of dyspepsia, with 51% of the patients reporting epigastric pain
(EPS) and 47% postprandial discomfort (PDS) Heartburn prevalence was
addressed among the symptomatic population and 35.3% had this symptom at
least once a month and 11.1% at least once a week.

In Spain, a cross-sectional study identified a 31.6% prevalence of GERD. In

Belgium, the prevalence observed was 28% . An Australian study showed that
56% of the individuals reported GERD symptoms at least once in a lifetime, and
37% had these symptoms at least once every four months . In Denmark, in 1994,
the heartburn prevalence was 38% among men and 30% among women

In Southern Brazil, a 48.2% heartburn prevalence was observed, however,

among the urban Brazilian population, the prevalence was 11.9% A literature
review reported that the variation in the prevalence of these symptoms could
range from 10% to 48% (heartburn), 9% to 45% (acid regurgitation) and 21% to
59% for these symptoms combined

A meta-analysis of international studies observed a frequent heartburn

prevalence (which occurs at least once per month) between 5% and 20% in the
West and up to 5% in East these results are a little lower than those observed in
this study.
In a population study carried out in Asia, the authors detected 20.2% of
epigastric pain and only 2.1% of heartburn The variation observed in different
countries can suggest a difference in the gastrointestinal symptom development
pattern between the Eastern and Western populations and different diagnosis
instruments used.

As the FD and GERD symptoms are often related to the intake of certain foods,
this association draws attention. Two studies observed that the ingestion of fatty
foods can worsen dyspeptic symptoms, and that postprandial fullness is related
to the amount of food ingested and the amount of fat contained in the food. These
studies therefore contribute to the findings in this study, since it was observed
that 35.4% of the symptomatic patients have reduced bulky and/or greasy meals.

The lifestyle of patients with dyspepsia was evaluated in several studies, and
factors such as smoking and high intakes of caffeine may cause or exacerbate
dyspeptic symptoms. This was also observed in this study, since most of the
participants who changed their habits regarding caffeine (93.7%) and cigarette
(64.7%) consumption belong to the group that presented gastrointestinal
symptoms. However, no firm evidence has proven the value of these approaches,
and only a minority of patients seem to benefit from these approaches in clinical
practice.

Although FD is a very common clinical condition, few prevalence studies were

carried out among the general population, especially those adopting the Rome III
criteria. As observed in different studies conducted in different countries, a
higher prevalence of FD has been observed among women, with a significant
variation, and when heartburn symptoms were excluded the prevalence dropped.
The FD prevalence studies present huge variations according to the region,
diagnosis criteria and instruments adopted. Generally, the prevalence of FD is
lower in the East than the West , and greater when the Rome I or II criteria is
adopted (especially due to greater symptom periods, which can possibly increase
the prevalence). Regardless of the data obtained, it is necessary to point out a
limitation in these results, that cannot be generalized for the entire population
with dyspeptic symptoms and heartburn, because a representative sample has
not been used.

CONCLUSION

Dyspeptic symptoms and heartburn are prevalent symptoms in Brazilian adult

urban population. The prevalence of FD was in agreement with the latest results
from the literature that also used the Rome III criteria. In addition, it has
observed that heartburn at least once per month was frequent as observed in
other countries. The change of life habits and the use of medication to relieve
symptoms were related to the decrease in the symptoms. In general, despite the
variation between countries, it was observed that the prevalence of the FD is
lower in the East than West greater when adopts Rome I or II criteria, and lower
when excluding heartburn.
Authors' contributions

Almeida AM participated in the study design, data interpretation, manuscript

writing, and she revised the final version of the manuscript to be published;
Martins LAG participated in the protocol/project development, data collection
and manuscript writing/editing; Cunha PLT participated in the protocol/project
development, data collection and manuscript writing; Brasil VW participated in
the protocol/project development, data collection; Flix LGF participated in the
protocol/project development, data collection; Passos MCF participated in the
study design, data interpretation, manuscript writing, and she revised the final
version of the manuscript to be published. Study supervision: Almeida AM and
Passos MCF.

ACKNOWLEDGMENTS

To Dr. Nulma Souto Jentzsch for her help with study design. To Isabel Cristina
Gomes for her help in the statistical analysis.
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ANALITIK

The relationship between in-hospital location and outcomes of care in patients

diagnosed with dementia and/or delirium diagnoses: analysis of patient journey

Abstract

Background

The discrepancy between the number of admissions and the allocation of hospital beds means
that many patients admitted to hospital can be placed in units or wards other than that which
specialise in the patients primary health issue (home-ward). These patients are called
outlier patients. Risk factors and health system outcomes of hospital care for outlier
patients diagnosed with dementia and/or delirium are unknown. Therefore, the aim of this
research was to examine patient journeys of people with dementia and/or delirium diagnoses,
to identify risk factors for inlier or outlier status and patient or health system outcomes
(consequences) of this status.

Methods

A retrospective, descriptive study compared patients who had dementia and/or delirium
according to the proportion of time spent on the home ward i.e. inliers or outliers. Data
from the patient journey database at Flinders Medical Centre (FMC), a public hospital in
South Australia from 2007 and 2014 were extracted and analysed. The analysis was carried
out on the patient journeys of people with a dementia and/or delirium diagnosis.

Results

When 6367 inpatient journeys with dementia and/or delirium within FMC were examined,
the Emergency Department (ED) Length of Stay (LOS) after being admitted as inpatient was
prolonged for outlier patients compared to inlier patients (OR: 1.068, 95% CI: 1.057
1.079, p=0.000). However, the inpatient LOS foroutlier patients was only marginally
shorter than that of the inlier patients (OR: 0.998, 95% CI: 0.9980.998, p=0.000). The
chances of dying within 48 h of admission increased for outlier patients (OR: 1.973, 95%
CI: 1.1583.359, p=0.012) and their Charlson co-morbidity Index was higher (OR: 1.059,
95% CI: 1.0211.10, p=0.002). Completion of discharge summaries within 2 days post-
discharge for outlier patients was compromised (OR: 1.754, 95% CI: 1.4922.061,
p=0.000).Additionally, outlier patients were more likely to be discharged to another
hospital for other care types not offered at FMC (OR: 1.931, 95% CI: 1.5592.391,
p=0.000).

Conclusion

An examination of the patient journeys at FMC has determined that the health system
outcomes for patients with dementia and/or delirium who are admitted outside of their home-
ward are affected by in-hospital location despite the homogenous nature of the study
population.

Keywords

Dementia and/or delirium Health care delivery Public hospitals Patient journey Outcome and

process assessment (healthcare) Ward outliers

Background

Dementia and/or delirium affect a growing number of older adults. In Australia, dementia is
projected to remain the third leading cause of disability burden and fourth leading cause of
overall burden of disease until at least 2020 [1]. In 2011, about 9% of Australians aged
65 years and over had dementia [2]. Patients with dementia have an increased risk of delirium
and dementia is often a comorbid condition for delirium [3, 4, 5, 6]. Delirium is also common
in hospitalised elderly patients [3]. Distinction between dementia and delirium in older
people is complicated as dementia co-occurs in most of delirium cases [5, 7]. On the other
hand, it is also probable for patients with delirium to be misdiagnosed as having dementia [8].
The projected increase in the older population, many of whom have been diagnosed with
dementia, increases the demand for care in public hospitals [9].

Australian public hospitals often work at high levels of bed occupancy, generally between 95
and 100% [10]. As a consequence, it is often difficult to admit patients into the home-ward
that corresponds to the clinical team managing the patients primary health care need. Thus
patients may have to spend periods of time in outlier wards until a suitable bed becomes
available in their home-ward [10]. This disrupts both ward-based and team-based models of
care which may lead to poor quality of care [10].

A recent study found that there was a strong association between time spent in outlier wards
and the number of emergency calls to Medical Emergency Teams (METs). The study used
MET activation as a measure for adverse events [11]. Other studies have shown that, patients
admitted to outlier wards (surgical patients on medical ward) are prone to medication errors
[12], prolonged hospital Length of Stay (LOS) for patients with heart failure [11], greater in-
hospital mortality and lower rates of discharge summary completion [10]. Being an inpatient
in a hospital can be a confusing experience and harmful for a person with dementia [13].
Dementia patients in acute hospitals are also known to receive inadequate or inappropriate
quality care [14]; dementia patients with palliative care needs are less frequently referred to
palliative care teams and receive fewer palliative medications [15]. In addition, the Australian
Governments prescribed target for a patients LOS in the Emergency Department (ED) is
less than 4 h likely increases the frequency of patients being sent to outlier wards [1, 10].
Patients in outlier wards maybe be transferred to the appropriate home-ward when such ward
becomes available. Numerous ward movements may be detrimental to the health of elderly
patients. Moving elderly patients at hospital has been associated with an increased incidence
of delirium [16].

Elderly dementia and/or delirium patients with extended LOS in outlier wards and receiving
fragmented care delivery are at risk of poor hospital outcomes. There are no known studies
done so far on the effects of a patients outlier ward status on hospital outcome measures for
dementia and/or delirium patients. Therefore the aim of this study is to identify the risk
factors for inlier or outlier status and patient or health system outcomes of this status both
during and after their hospital admission.

Methods

Study design and setting

All patients admitted to the Flinders Medical Centre (FMC), who had been coded with a
dementia and/or delirium diagnoses in the hospital separation data for the period 20072014,
were included in the study. FMC is a 500 bed public teaching hospital in South Australia with
approximately 40,000 ED presentations per annum. FMCs inpatient services comprise of
short-stay and long-stay units with defined home-ward location. A home-ward is defined as
the ward where the multidisciplinary team primarily responsible for the care of a particular
patient is located [10]. The wards that were home-wards were operationally defined
throughout the period of observation. The computerised bed management system used at
FMC instantaneously updates its information pertaining to allocated home-wards for each
specialist unit according to their continuously updated business rules. Accordingly the ward
inlier or outlier status of a patient admitted to a ward is also automatically reflected and
considerable care is taken by FMC staff to keep the relevant data updated to the specialist
team responsible for delivery of care. Furthermore, the percentage of patients who were
outliers was a regularly reported hospital indicator as such this report relies on accurate
information on ward inlier or ward outlier status [10].

If a patients home-ward is not available at admission, the patient might be housed in outlier
ward/s including boarding in the ED for a period of time until an outlier ward or the home-
ward becomes available. During the time when patients are housed in outlier ward/s, the care
responsibilities remain with the home-ward team allocated to the care of the patient. As such,
any amount of time spent away from the patients home-ward is considered as outlier time by
the hospital.

FMC also has an Acute Medical Unit (AMU) comprising of 30 beds. The AMU admits all
General Medicine (GM) patients and Acute Care of the Elderly (ACE) patients where; (i)
short-stay patients are cared for by the AMU team, in which case, the AMU is a home-ward
for these patients; (ii) patients are housed temporarily in the AMU whilst the AMU team
allocates an appropriate long-stay team, therefore the home-ward designation for these
patients will eventually change; and (iii) patients who require initial cardiac monitoring and
closer observation for a short time are housed temporarily at the AMU prior to their
admission to long-stay home-wards.

Data

Hospital ED presentations from 1/01/2007 to 22/09/2014 for patients with a dementia

and/or delirium diagnoses based on the International Classification of Diseases, Tenth Revision,

Australian Modification (ICD-10-AM) recorded as either the principal diagnosis and/or included as
part of the 24 additional diagnoses were extracted from FMCs ED database. The ICD-10-AM codes

used are listed in Table 1. The relevant inpatient data were extracted from FMCs in-house ED

database retrospectively and were linked to FMCs patient journey database to extract information

on ward movements for each patient from their time of admission until discharge. The FMC patient

journey database is a continuously updated extract of the hospitals patient admission and tracking

databases. All inpatient movements between wards and between units are time-stamped and

recorded. The FMC patient journey database also records post-discharge deaths extracted from the

register of births, deaths and marriages.

Table 1

Dementia and/or delirium ICD-10-AM codes

Dementia codes

F00.0* Dementia in Alzheimers disease with early onset (G30.0 )

F00.1* Dementia in Alzheimers disease with late onset (G30.1 )

F00.2* Dementia in Alzheimers disease, atypical or mixed type (G30.8 )

F00.9* Dementia in Alzheimers disease, unspecified (G30.9 )
F01.0 Vascular dementia of acute onset
F01.1 Multi-infarct dementia
F01.2 Subcortical vascular dementia
F01.3 Mixed cortical and subcortical vascular dementia
F01.8 Other vascular dementia
F01.9 Vascular dementia, unspecified

F02.1* Dementia in Creutzfeldt-Jakob disease (A81.0 )

F02.2* Dementia in Huntingtons disease (G10 )

F02.3* Dementia in Parkinsons disease (G20 )

F02.4* Dementia in human immunodeficiency virus [HIV] disease (B22 )
F02.8* Dementia in other specified diseases classified elsewhere
Dementia (in):

cerebral lipidosis (E75.- )

epilepsy (G40.- )

hepatolenticular degeneration (E83.0 )

hypercalcaemia (E83.5 )

hypothyroidism, acquired (E01.- , E03.-)

intoxications (T36-T65 )

Lewy body disease (G31.3 )

multiple sclerosis (G35 )

neurosyphilis (A52.1 )

niacin deficiency [pellagra] (E52 )

polyarteritis nodosa (M30.0 )

systemic lupus erythematosus (M32.- )

trypanosomiasis (B56.- , B57.-)

uraemia (N18.5 )

vitamin B12 deficiency (E53.8 )
F03 Unspecified dementia
Delirium Codes
F05.0 Delirium not superimposed on dementia, so described
F05.1 Delirium superimposed on dementia
F05.8 Other delirium
F05.9 Delirium, unspecified

*The asterisk symbol denotes a code describing the manifestation of a disease and should
always be assigned together with the appropriate aetiology code

The dagger symbol denotes a code describing the aetiology or underlying cause of a disease
and should always be assigned together with the appropriate manifestation code

The initial data extraction of 8184 records of individual patients from the hospitals ED

database was merged with data from the hospitals patient journey database using deterministic

record linkage methods. Deterministic linkage requires an exact match between the identifying

variables for data to be attributed to the same individual (as opposed to probabilistic linkage which

can more easily account for some variation in the identifying data) [17]. A total of 1111 in-scope ED

presentations were not admitted as inpatients and therefore their records were not present in the

patient journey database and so were excluded from the analysis, giving a new sample size of 7073

patient records. Three patient journeys were further excluded from the sample because of

incomplete values and the absence of valid inpatient ward records, giving a possible sample size of

7070 patients. Inpatient LOS (hospital stay) is the difference between date/time of admission and

date/time of discharge. An admitted patient may spend part or all of their hospital stay in a home-
ward. Admitted patients generally move from an outlier ward to a home-ward. If the patient

spent>=70% of their hospital stay in home-ward/s, we defined their status for the purposes of this

study as an inlier patient. If the patient spent>=70% of their hospital stay outside their home-

ward, we defined their status as an outlier patient. This>=70% threshold captured 90% of the

study population leading to a final sample size of 6367. The process of data inclusion and exclusion is

depicted in the flow diagram (Fig. 1). A>=70% threshold was also used to determine inlier versus

outlier classification based on a previous study [10].

 Fig. 1

Flowchart of data inclusion and exclusion

Dependent variable

The dependent variable was the status of a patient as outlier patient versus inlier patient as
defined for the purpose of this study. Accordingly, those patients spending>=70% of their
hospital stay in outlier ward/s were classified as outliers and those patients spending>=70%
of their hospital stay in home-ward/s were classified as inliers. This dependent variable is a
process related outcome. Process measures are used to assess delivery of care and
coordination of care to improve patient health related measures [18].

Independent variables

Independent variables used to adjust for available confounders in the logistic regression
model were: age; inpatient LOS; total time spent in the ED after admission; nature of
separation (home, other hospitalup transfer, other hospitaldown transfer, nursing home or
hostel, in-hospital mortality, other types of discharges); in-hospital mortality within 48 h of
admission; if discharge summaries were sent within 2 days of discharge; episode of care
(acute and non-acute); if patient died within 28 days of discharge; sex; principal diagnosis of
dementia (yes, no); Charlson co-morbidity index [19]; source of referral (Other or unknown,
other private medical practise, residential aged care facilities, inter-hospital transfer,
outpatient department, casualty/emergency); and treatment priorities (Australasian Triage
Scale (ATS) 15, booked/elective patients, not assigned). The variables age, sex, principal
diagnosis of dementia and Charlson co-morbidity index are risk factors, whereas the other
variables are health system outcomes.

Statistical analysis

Descriptive statistical analyses of patient demographics were performed. Categorical

variables were compared using Chi-squared tests, and continuous variables were compared using

Wilcoxon-MannWhitney tests. Treatment priority; episode of care (Table 2); discharged from

outlier ward (number of patients discharged from an outlier ward) and admission decision made

inside of working hours (Table 3) were compared using the two-sample test of proportions. Inside

working hours are from 0800 to 1800. Logistic regression model was used to analyse the risk factors

and health system outcomes where these potential confounders of clinical interest were included as

independent variables in comparing the adjusted odds ratio of outlier patients versus inlier

patients with respect to the variable. A p value of <0.05 was considered as statistically significant.
The Charlson co-morbidity index [18] as modified by Quan and colleagues [20] was calculated for all

patients. The logistic regression model was assessed using Hosmer and Lemeshows goodness-of-fit

test. In addition a sensitivity analysis was undertaken to assess the impact of a different definition of

the dependent variable [21]. The purpose of the sensitivity analysis was to assess the robustness of

the results. The decision on the cut-off point used in the sensitivity analysis was done in consultation

with senior doctors and hospital epidemiologists who understand the real-world nature of these

data. For the sensitivity analysis; if the patient spent 100% of their hospital stay in home-ward, we

defined their status as an inlier patient. If the patient spent 100% of their hospital stay outside their

home-ward, we defined their status as an outlier patient. This reduced the eligible cohort to 1269

(18%). Statistical analyses were performed using STATA 13.0 (StataCorp., College Station, TX, USA).

Table 2

Patient characteristics

Total Inlier (n=5367, Outlier (n=1000 p-

(n=6367) 84.29%) 15.71%) value
Demographics
Age, mean (SD) 81.07 (11.48) 80.83 (11.72) 82.39 (9.98) 0.0006
Charlson Index, mean (SD) 2.03 (2.06) 2.03 (2.07) 2.05 (1.96) 0.1534
Female, n (%) 3563 (55.96) 3005 (55.99) 558 (55.80) 0.9114
Principal Diagnosis coded
725 (11.39) 597 (11.12) 128 (12.8) 0.1254
with Dementia, n (%)
Treatment Priority
ATS 1, n (%) 342 (5.37) 296 (5.52) 46 (4.60) 0.2386
ATS 2, n (%) 1282 (20.14) 1071 (19.96) 211 (21.10) 0.4072
ATS 3, n (%) 2982 (46.84) 2474 (46.10) 508 (50.80) 0.0062
ATS 4, n (%) 1194 (18.75) 998 (18.60) 196 (19.60) 0.4548
ATS 5, n (%) 61 (0.96) 44 (0.82) 17 (1.70) 0.0087
ATS 6, n (%)- (Not triaged) 52 (0.82) 51 (0.95) 1 (0.10) 0.0061
Not assigned, n (%) 454 (7.13) 433 (8.07) 21 (2.10) 0.0000
Episode of Care
Acute, n (%) 6225 (97.77) 5246 (97.75) 979 (97.90) 0.7613
Non-Acute, n (%) 142 (2.23) 121 (2.25) 21 (2.10) 0.7613
 Total Inlier (n=5367, Outlier (n=1000 p-
(n=6367) 84.29%) 15.71%) value
Nature of Separation
Home, n (%) 3664 (57.55) 3117 (58.08) 547 (54.70) 0.0473
Other hospital up transfer, n
621 (9.75) 445 (8.29) 176 (17.60) 0.0000
(%)
Nursing home or hostel, n (%) 516 (8.10) 449 (8.37) 67 (6.70) 0.0763
In-hospital mortality, n (%) 520 (8.17) 424 (7.90) 96 (9.60) 0.0715
Other hospital down
973 (15.28) 873 (16.27) 100 (10.00) 0.0000
transfer, n (%)
Other types of discharge, n
73 (1.15) 59 (1.10) 14 (1.40) 0.4122
(%)
Table 3

Health system outcomes (or consequences) variables

Inlier Outlier
Total p-
(n=5367, (n=1000
(n=6367) value
84.29%) 15.71%)
Time spent boarding in ED (Hrs),
5.47 (6.80) 4.87 (5.76) 8.73 (10.17) 0.0000
mean (SD)
In-hospital LOS (Hrs), mean (SD) 278.75
299.82 (441.11) 165.69 (255.82) 0.0000
(including boarding time) (420.32)
In-hospital mortality, n (%) 520 (8.17) 424 (7.90) 96 (9.60) 0.072
In-hospital mortality within 48 h of
94 (1.48) 62 (1.16) 32 (3.20) 0.000
admission, n (%)
Mortality within 28 days of
914 (14.36) 761 (14.18) 153 (15.30) 0.353
discharge, n (%)
Mortality within 28 days of
discharge (excluding in hospital 394 (6.19) 337 (6.28) 57 (5.70) 0.485
death), n (%)
Readmitted within 7 days, n (%) 145 (2.28) 120 (2.24) 25 (2.50) 0.607
Readmitted within 28 days, n (%) 328 (5.15) 281 (5.24) 47 (4.70) 0.482
Discharge summary sent within two
4873 (76.54) 4217 (78.57) 656 (65.60) 0.000
days of discharge, n (%)
Discharge summary sent within
5538 (86.98) 4741 (88.34) 797 (79.70) 0.000
7 days of discharge, n (%)
Discharged from Outlier Ward, n
995 (15.63) 153 (2.85) 842 (84.20) 0.000
(%)
Admission decision made inside of
2771 (43.52) 2387 (44.48) 384 (38.40) 0.000
working hours (0800 1800), n (%)
 Results

Patient and admission characteristics

A total of 7070 patients admitted to FMC had hospital separation records that contained
diagnoses of dementia and/or delirium according to the ICD-10-AM codes (Table 1) during
the study period. These patients had a mean age of 81 years. The age for about 92.0% of
these patients were more than 65 years (age range: 65103). They represented 1.9% of the
total patients admitted to the hospital, and 5.5% of those FMC patients aged 65 years and
over who were admitted during the study period. About 90.0% of these patients (n=6367)
were either classified as outlier patients (n=1000; 15.7%) or as inlier patients (n=5367;
84.3%). The episode of care for about 98.0% (n=6225) of the cohort was classified as acute.

Most of the outlier and the inlier patients were triaged in the ED and were assigned to one
of the five ATS categories. About 8.0% (n=506) of the cohort; mainly the inlier patients
were not triaged (ATS 6) and/or their priority was not assigned. This was likely due to being
admitted as elective patients, having been transferred from another hospital for admission, or
patients who followed a direct pathway to a specific ward such as an obstetrics/gynaecology
admission.

The source of referral recorded were admission through the hospitals ED as a

casualty/emergency admission (50.2%; n=3195), other or unknown referral (37.7%;
n=2403), referral from other private medical practice (2.6%; n=166), referral from
residential aged care facilities (4.5%; n=288), inter-hospital transfer (1.8%; n=114) and
referral from the outpatient department (3.2%; n=201). At FMC, those patients presenting to
the ED that require admission are referred for admission by the ED doctors to an appropriate
inpatient team (unit). Upon consultation with the units consultant, some patients may be
admitted directly to a unit after assessment by a doctor at a private practice, outpatient
department or at another public hospital. These patients are admitted directly with no further
input from the ED doctors unless the patient requires immediate treatment at the ED.

The top ten treated principal conditions recorded were: Urinary tract infection (5.5%),
Pneumonia (5.4%), Pneumonitis due to inhalation of food and vomit (3.4%), Midcervical
fracture of femur (2.9%), Unspecified dementia (2.8%), Delirium unspecified (2.7%),
Delirium superimposed on Dementia (2.6%), Alzheimers disease (2.3%), Fracture of greater
trochanter of femur (2.0%) and Syncope and collapse (1.9%). Although dementia and/or
delirium were the principal diagnosis in 11.4% of the cohort but; Dementia, Delirium and
Alzheimers disease were the primary condition treated only for about 10% of the cohort
during their episode of care at the hospital. Treatment is performed after further examination
of the patient; therefore there might be cases where the primary treatment offered may not be
in alignment with the initial (principal) diagnosis recorded at the time of admission.
 Relationship between dependent variable and independent variables (risk factors and health

system outcome measures)

ATS category

Based on univariate logistic regression analysis and after controlling for independent
variables, the outlier patients are more likely to be triaged under ATS 5 category when
compared with the inlier patients (OR: 2.519, 95%, CI: 1.2714.994, p=0.008). Patients
triaged under ATS 5 category are considered to be less urgent and their clinical outcome are
considered not to be significantly affected if treatment is delayed for up to two hours [22].

Charlson co-morbidity index

Mean Charlson co-morbidity index was 2.0; however, after adjusting for independent
variables, the Charlson co-morbidity index for the outlier patients is more likely to be
higher than for the inlier patients (OR: 1.059, 95% CI: 1.0211.099, p=0.002).

ED LOS

During the study period, the average ED LOS was 5.5 h. Outlier patients stay in the ED was

3.9 h longer than that of inlier patients. For the outlier patients, average ED LOS was persistently

higher than the inlier patients and persistently higher than the entire cohort (presented in Fig. 2).

As expected the ED LOS worsened during the winter months for both outlier and inlier patients

corresponding with the higher numbers of admissions (presented in Fig. 3). During the winter

months of June, July and August the average ED LOS for outlier patients versus inlier patients were

(10.0 cf. 5.3 h), (10.3 cf. 6.2 h) and (9.6 cf. 6.0 h) respectively (presented in Fig. 2). Regardless of

seasonal variation, ED LOS for the outlier patients remained higher than the inlier patients.

Additionally, despite the drop in admissions to the hospital on the weekend (presented in Fig. 4), the

average ED LOS was higher than week days (presented in Fig. 5). The average ED LOS was 5.9 h on

Saturday and 6.7 h on Sunday. The average ED LOS for outlier patient versus inlier patients were

(9.7 cf. 5.9 h) on Saturdays and (10.4 cf. 6.0 h) on Sundays. After adjusting for independent variables,

outlier patients LOS in the ED continued to be prolonged; outlier patients ED LOS doubled (OR:

1.068, 95% CI: 1.0571.079, p=0.000) when compared with inlier patients.
 Fig. 2

Monthly dementia and/or delirium average ED LOS

Fig. 3

Monthly dementia and/or delirium admission

 Fig. 4

Daily dementia and/or delirium admission

Fig. 5

Daily dementia and/or delirium average ED LOS

Inpatient LOS

The average inpatient LOS for those patients aged 65 years and over and coded with a

dementia and/or delirium diagnosis was 260.4 h or 10.9 days. Outlier patients inpatient LOS was

134.1 h or 5.6 days less than that of inlier patients. We confirmed that the overall longer inpatient

LOS for the inlier patients was not the result of our>=70% classification threshold. In other words,

for the inlier patients; LOS in outlier wards/s was only a small percentage of the overall inpatient

LOS (presented in Fig. 6) and the prolonged inpatient LOS was not a consequence of extended stay in

outlier wards/s whilst a bed in home-ward was being sourced. Inlier patients only spent on average

about 4.8% of their inpatient LOS in outlier ward/s and the outlier patients only spent on average

about 6.3% of their inpatient LOS in home-ward/s. After adjusting for independent variables,

outlier patients inpatient LOS continued to be shorter than inlier patients. Therefore, outlier

patients are more likely to stay at the hospital for a shorter duration when compared with inlier

patients (OR: 0.998, 95% CI: 0.9980.999, p=0.000).

 Fig. 6

Average LOS comparison for Inliers and Outliers

In-hospital mortality

About 8.2% of the entire cohort died during their episode of care at the hospital. The
proportion of outlier patients who died in the hospital within 48 h of admission and within
28 days of discharge was higher than the proportion of inlier patients. However, only death
within 48 h of admission was statistically significant between the outlier and the inlier
patients. After controlling for all other independent variables, outlier patients are more
likely to be at risk of dying in the hospital within 48 h of admission (OR: 1.973, 95% CI:
1.1583.359, p=0.012) compared with inlier patients showing inferior health systems
outcome for the outlier patients.

Discharge summary

A further finding demonstrates that discharge summaries were not sent within 2 days as
required by the hospital for about 34% of the outlier patients as opposed to about 21% of
inlier patients. After adjusting for the independent variables, outlier patients are more
likely to be at risk of not receiving their discharge summaries within 2 days of discharge from
hospital (OR: 1.75, 95% CI:1.4922.061, p=0.000) when compared with inlier patients
posing concerns for continuity of care.

Nature of separation (destination after eventual hospital discharge)

The majority of the patients were discharged back to their usual place of residence prior to
their hospital admission. A higher proportion of outlier patients (17.6%) than inlier
patients (8.3%) were transferred to another hospital (up transfer) to continue their care
(p=0.000). Patients are up transferred from FMC to another hospital if they require
specialised care not offered at FMC; such care may entail rehabilitation or palliative care.
After adjusting for independent variables, outlier patients are more likely to be up
transferred (OR: 1.931, 95% CI=1.5592.391, p=0.000) when compared with inlier
patients.

Sensitivity analysis

The results of a sensitivity analysis based on 100% threshold for the dependent variable

reduced the eligible cohort to 18% instead of the 90% achieved with the>=70% threshold. About

59% (n=750) observations were dropped because of collinearity and the model could not be fit with

a number of the independent variables. The independent variables affected were treatment

priority, time spent boarding in the ED, in-hospital mortality within 48 h of admission and

mortality within 28 days of discharge. As such the results of this paper are based on the>=70%

threshold which was based on a model that was able to fit the important variables of interest. The

characteristic of excluded patients as a result of applying the>=70% threshold is presented in

Table 4. The results are within the expected range with about 64% (n=452) of these patients

spending more than half of their hospital stay in home-ward/s.

Table 4

Excluded patient characteristics

Total (n=703)

Demographics
Age, mean (SD) 81.84 (11.01)
Charlson Index, mean (SD) 2 (2.11)
Female, n (%) 391 (55.62)
Principal Diagnosis coded with Dementia, n (%) 105 (14.94)
Treatment Priority
ATS 1, n (%) 30 (4.27)
ATS 2, n (%) 156 (22.19)
ATS 3, n (%) 362 (51.49)
ATS 4, n (%) 131 (18.63)
ATS 5, n (%) 6 (0.85)
ATS 6, n (%)- (Not triaged) 0
Not assigned, n (%) 18 (2.56)
 Total (n=703)

Episode of Care
Acute, n (%) 691 (98.29)
Non-Acute, n (%) 12 (1.71)
Nature of Separation
Home, n (%) 397 (56.47)
Other hospital up transfer, n (%) 67 (9.53)
Nursing home or hostel, n (%) 56 (7.97)
In-hospital mortality, n (%) 81 (11.52)
Other hospital down transfer, n (%) 94 (13.37)
Other types of discharge, n (%) 8 (1.14)
Time spent boarding in ED (Hrs), mean (SD) 8.25 (8.70)
In-hospital LOS (Hrs), mean (SD) (including boarding time) 234.01 (286.73)

Discussion

The analyses of these data in this study demonstrates that the location of care of a patient
with dementia and/or delirium diagnoses during an episode of inpatient care at a tertiary
hospital can affect their health system outcomes. In this study, we found that the health
system outcomes were inferior for the outlier patients even after adjusting for confounding
factors. The higher likelihood of ED presentations attributed to the aging population coupled
with higher hospital admission rates for people with dementia [23] and that room transfers
promote the development of delirium [16], calls for extra attention to be given when hospitals
are deriving policies surrounding bed allocation to units predominantly responsible for the
care of these patients. About 72% of our entire patient cohort was assigned to ATS 1 to ATS
3 categories; required urgent assessment by a clinician within the 30 min prescribed
assessment time for ATS 3 patients [22]. However, the adjusted ATS category shows that the
outlier patients are more likely to be assigned to ATS 5 category compared to the inlier
patients. Furthermore, because of inability to provide information during admission, the
likelihood of under triage is higher for cognitively impaired patients [24]. These outlier
patients could potentially spend up to 2 h or longer in the ED from the time of their triage to
when the admission decision is made. Being acutely unwell and having to wait for up to 2 h
or more for assessment may contribute to rapid functional decline of these outlier patients.
In the busy ED environment, especially when patients fall in the non-urgent treatment
category, busy ED staff may not recognise the cognitive impairment in these patients. Not
recognising cognitive impairment may lead to significant functional decline in elderly
patients [25]. The outlier patients are more likely to have a higher Charlson co-morbidity
index indicating that these patients are a sicker cohort, as such not recognising the cognitive
impairment may lead to further deterioration of their overall health status and cognitive
ability. Co-morbidity burden has been associated with rapid cognitive decline especially in
patients aged 65 and older diagnosed with Alzheimers disease [26].
The outlier patients being sicker and their treatment priority in the ED categorised as less
urgent will naturally contribute to prolonged ED LOS. Our study showed that outlier
patients ED LOS was longer than inlier patients. As expected the ED LOS was higher
during busy periods (e.g. winter months and weekend) for the entire cohort and this increase
in ED LOS was exacerbated for the outlier patients. Moreover, the daily and monthly
pattern of ED LOS for the outlier patients was consistently higher than that of inlier
patients. The prolongation of ED LOS for the outlier patients remained significant even
after adjusting for independent variables. Less urgent ATS categories may partly contribute
to the longer ED LOS for the outlier patients. The less urgent triage category and its
association with prolonged assessment time leading to eventual admission of a patient has
been studied before on a group of GM patients at the same hospital [27]. Another study also
reported that elderly patients with dementia were predictors of prolonged ED LOS [28].

The presence of ED congestion during periods of high occupancy rates, where ED is

incapacitated by patients waiting for unavailable beds, makes the likelihood of finding a
home-ward even harder [27]. Less than half or 44.0% of the entire cohort managed direct
admission to their home-ward during the study period raising concerns of severe bed shortage
in home-wards for this dementia and/or delirium patients. Our study showed that about
16.0% of the entire cohort and the majority of the outlier patients (84.0%) were discharged
from an outlier ward without ever making it to a home-ward.

Despite the prolonged ED LOS, the adjusted inpatient LOS for the outlier patients were
shorter compared to the inlier patients. This result did not come as a surprise as it was
similar to the findings from an earlier study of GM patients at the same hospital [10], where
the inpatient LOS was shorter in outlying patients. It may be debated that the presence of the
Acute Medical Unit (AMU) facility at the hospital, which generally admits short-stay patients
(LOS of 24 to 48 h), may have contributed to the shorter inpatient LOS for the outlier
patients, especially if the predicted short-stay patients are predominantly housed in AMU. We
confirmed that AMU does not influence the findings of our study. Only about 27.0% of the
outlier patients were ever admitted in the AMU as opposed to 43.0% of the inlier patients.
It may also be argued that functional assessment and/or sub-acute rehabilitation may dictate
that the outlier patients move to a home-ward later in time and become classified as inlier
patients, thus increasing the overall LOS for the inlier patients in this study. Our method of
using the>=70% cut-off point to classify the outlier and the inlier patients in this study is
robust and prevents this occurrence. At the end of their stay, the inlier patients stayed 286 h
(12 days) in home-ward and only 14 h in outlier ward/s on average. Whereas the outlier
patients stayed 155 h (6.50 days) in outlier ward/s and 10 h in home-ward on average. These
data demonstrate that the prolonged inpatient LOS for inlier patients was not as a
consequence of a prolonged stay in outlier ward/s whilst a bed in home-ward is being sourced
(presented in Fig. 6). Similar to the previous findings of other researchers [29] we do not
equate a shorter LOS with improved quality of care for the outlier patients; there is no
difference in the readmission rate between outliers and inliers. In-hospital mortality rate,
the risk of readmission and timely dissemination of discharge summaries reflects quality of
care.

Patient age and co-morbidity separately impose significant effects on in-hospital mortality,
LOS and risk of readmission [15]. Interestingly, the risk of readmission was not significantly
different between the outlier and the inlier patients. The adjusted risk of death within 48 h
of admission was higher for the outlier patients. For the entire cohort about 70.0% of deaths
within 48 h of admission occurred in outlier wards. The higher mortality in the outlier
patient group may not only reflect the system of care provided but also that these patients
maybe more acutely unwell. The higher mortality figures are a significant cause for concern
if our data reflect admitting patients initially to outlier wards as a common phenomenon.
What our study cannot tell us is if relocating these patients promptly to home-ward has a
protective effect for mortality.

Furthermore, once discharged from the hospital, the discharge summaries containing
information about an episode of hospital care are less likely to be sent to the primary health
care practitioners within 2 days of discharge compromising the continuity of care for the
outlier patients. Timely dissemination of discharge summaries is essential for continuity of
care and for better health system outcomes [30]. In addition to being clinically complex, the
outlier patients are more likely to be transferred to another hospital to continue with care
that is not available at FMC making timely completion of discharge summaries for these
patients even more critical.

Strength and limitations

Although dementia coding in administrative datasets is known to be low, studies using

administrative dataset and ICD codes have been validated as an important starting point on
dementia prognosis [31]. Research demonstrates significant under-coding of dementia and of
patients with cognitive deficits [8, 32]. A diagnosis of dementia may not be recorded in
hospital data if the condition does not affect the resource usage or the provision of care
during the hospital stay [33]. In this study the dementia and/or delirium patients were
identified if a dementia and/or delirium diagnosis were present in a patients hospital
admission data therefore the patients with dementia and/or delirium that affected their care
were more likely to have been identified as having the condition. The study compares the
health system outcomes of hospitalisation for outlier versus inlier patients of all patients
diagnosed with dementia and/or delirium (e.g. all patients had the same diagnosis), therefore
not faced with issues apparent when comparing population with and without the diagnosis. In
addition, our method of outlier and inlier classification is dependent on the proportion of time
spent inside or outside of a home-ward rather than using the more simplistic way of directly
classifying those who stayed outside of their home-ward as outliers. However, a sensitivity
analysis undertaken based on 100% threshold for the dependent variable, although under a
more stringent definition of outlier and inlier status, did not allow for full investigation of
all the covariates (independent variables) of interest. Furthermore, although spending the
entire hospital stay in a home-ward would be an ideal situation for a patient; this is unusual
and difficult to achieve in hospitals currently, especially when the hospital is operating at
close to full capacity. The data clearly shows that the majority of patients stayed in both inlier
and outlier wards.

Our study has several limitations. It is retrospective and observational, and has relied on
information available in hospital administrative datasets and gave insight into health system
outcomes. Further research is needed to detect differences in actual care practices and
functional outcomes of the patients. About 38% of patients did not have a source of referral
and being an outlier was not associated with arriving in the ED without a referral as
majority were inlier patients (83.0%). This is one of the challenges of using administrative
datasets for research purposes. The process of collecting information changes over time and
largely dependent on reporting needs. Also, the data are derived from one hospital, albeit
covering various units within that hospital. Although within FMC there was a variation in the
coding practice of dementia and/or delirium patients over time, this work is an important
foundation for further analysis of hospital outcomes for the not insignificant number of
patients who have recognised cognitive impairment.

The work clearly needs replication elsewhere. Ethical and practical issues preclude a
randomised intervention trial of the study of outlier patient status, but a prospective
observational study would allow collection of robust clinical data currently not accessible
from administrative datasets. Future studies should include data on intensity of allied health
intervention offered to patients in home-wards versus outlier wards which benefit the patients
but may invariably increase the LOS. Such a study would be of further interest if it
incorporated comparison between two institutions, one of a business as usual type and
another with a holistic dementia care approach. Issues that could be studied in a prospective
study may include, appropriateness and impact on LOS versus investigation performed
during hospital stays, or the impact of decision making in relation to issues such as the need
for behavioural management, delirium identification in ED and other dementia-specific care.
Future research should also explore the effects of higher in-hospital mortality within 48 h of
admission versus shorter LOS for the outlier patients and the higher likelihood of hospital
up transfer versus shorter LOS for the outlier patients which our current research is not able
to answer.

Conclusion

Our study compares the risk factors and health system outcomes (or consequences) for
patients with dementia and/or delirium when these patients are housed in wards distant from
their home-ward using a large cohort of patients. We have studied one aspect of the impact of
the organisation of care provided to dementia and/or delirium patients in a busy tertiary
hospital in Australia. The ward location of a patients care appears to have substantial impact
on the health system outcomes; with prolonged ED LOS and the overall inpatient LOS
reduced for the outlier patients. Further research is needed to identify those factors that are
influencing reduced inpatient LOS to ensure that any organisational benefits that might derive
from a reduced LOS are not being obtained at the expense of less than optimal inpatient care.
Outlying patients had higher Charlson co-morbidity index and had higher chance of dying in-
hospital within 48 h of admission. Timely dissemination of discharge summaries was
compromised for outlying patients. Discharged outlying patients were more likely to be
transferred to another hospital to continue care at another hospital. Although, in some cases
staying in outlier ward (e.g. no location shift) might be perceived to be better for the patient
as it provides better continuity of care, our study shows that the health system outcome for
the outlying patients was poor.

Better acute care for frail dementia and/or delirium patients may reduce the burden of
hospital care overall and in turn reduce the rising cost of care attributed to dementia.
Administrative data sets are widely used as a starting point in dementia research; therefore it
is imperative to develop processes to improve dementia identification and coding in hospital
administrative data.

Abbreviations

ATS:
 Australian triage scale

CI:

Confidence interval

ED:

Emergency Department

FMC:

Flinders Medical Centre

ICD-10-AM:

International Classification of Diseases, Tenth Revision, Australian Modification

LOS:

Length of Stay

OR:

Odds ratio

Declarations

Acknowledgements

These authors gratefully acknowledge Dr Rebecca Biltons contribution in proof-reading the

article.

Funding

These authors gratefully acknowledge funding provided by the National Health and Medical
Research Council (NHMRC) Partnership Centre on Dealing with Cognitive and Related
Functional Decline in Older People. The contents of the published materials are solely the
responsibility of the Administering Institution, Flinders University, and the individual authors
identified, and do not reflect the views of the NHMRC or the RACFs involved in the
research.
 Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding
author on reasonable request.

Authors contributions

Lua Perimal-Lewis planned the study, collected data, and performed the statistical analyses of
the data. Clare Bradley confirmed that the statistical analyses was robust and assessed the
integrity and accuracy of data analysis. All authors participated in writing of the manuscript
and made expert contribution to the discussion. All authors had full access to the tables and
graphs used in the study. The final version of the manuscript has been read and approved by
all authors.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Ethics approval was granted by the Southern Adelaide Health Service/Flinders University
Human Research Ethics Committee (Application No: 425.14).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution
4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to the Creative Commons
license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data
made available in this article, unless otherwise stated.

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