Happy old peopleWhen considering admitting patients over the age of 65 for acute hospital care, alternatives such as hospital at home, admission to a local community hospital or extended stays and treatment in A&E are a viable option say NIHR-funded researchers from the University of Bristol and the University for the West of England (UWE Bristol). 

The research has shown that these interventions are safe, effective and have comparable mortality and clinical outcomes for patients with a range of acute and chronic conditions.

Professor Sarah Purdy and her colleagues identified, studied and summarised the highest quality research evidence published so far on five types of alternative to acute hospital admission:
• Interventions initiated by paramedics and other 999 ambulance staff;
• Alternatives delivered in hospital A&E (emergency) departments;
• Admission to a local community hospital;
• Hospital-type services delivered in the patient’s own home ‘hospital at home’;
• Hospital-type services delivered in a nursing or care home.

The researchers looked at the mortality and clinical outcomes for elderly patients with conditions such as chronic obstructive pulmonary disease (COPD), stroke, heart failure, pulmonary embolism and pneumonia. The research team found that, with the exception of stroke, these alternative are safe and can often be more cost-effective than acute hospital care. Information on costs are sparse and will differ between approaches. 

 Dr Alyson Huntley, co-author and Research Fellow at the University of Bristol’s Centre for Academic Primary Care, said: “Hospital at home for a patient with an exacerbation of COPD is likely to be much more intensive in resources and staffing and therefore more expensive than a patient treated at home with antibiotics for pneumonia who is checked on by phone and brief visits. The exception to the evidence of benefit of hospital at home is the treatment of stroke patients who fare much worse with hospital at home compared to a stroke unit.”

The differences in outcomes for stroke patients is due to the expertise of the stroke unit staff and therefore, in line with current NICE guidance for stroke, best care needs to be provided in specialist units.

Professor Sarah Purdy, GP and Associate Dean of the Faculty of Health Sciences at the University of Bristol, added: “Reducing unnecessary hospital admission and consequent length of stay is one of the biggest challenges currently facing the National Health Service. NHS England reports that there has been a 65 per cent increase in hospital admissions for those over 75-years-old in the last decade. Those over 85-years-old, now account for 11 per cent of emergency admissions and 25 per cent of bed days. This is complicated by the fact that, while for some older people the decision to admit is straightforward, for others the decision is uncertain. Our research has helped identify the difficulties of admitting older people appropriately into hospital.” 

Research is ongoing within CAPC and aims to develop and pilot an alternative to hospital intervention when appropriate for older people out of the acute hospital setting.