The number of people dying with dementia in England will soon exceed 200,000 people per year due to population ageing. Improving end-of-life care for these individuals, and supporting people to remain in community settings, are national priorities. Emergency hospital admissions by people with dementia in their last months of life is an indicator of potentially overaggressive care. We know that certain characteristics predict emergency admissions among people with dementia close to death. For example, having multiple chronic illnesses or being male were associated with more Emergency Department attendance in the last months of life, while living in a care home is associated with lower use of acute hospital services. However, less is known about how primary care services influence emergency admissions near the end-of-life in England.
This project aims to understand how primary care services (such as the number of contacts with General Practitioners and nurses at the GP practice, and continuity of care) and costs of them influence emergency admissions for people with dementia in the last 90 days of life. Understanding which individuals and healthcare services are associated with hospital admissions near the end of life could help to develop and improve primary care services and reduce reliance on emergency hospital care for individuals with dementia.
Background: The number of people dying with dementia in England is projected to increase x3 by 2040. Hospital admissions at the end-of-life can be deleterious and are potentially avoidable. Continuity of care with a GP and number of GP visits have been associated with lower hospital admissions in individuals with cancer. However the impact of primary care services on end-of-life hospitalizations for individuals with dementia is unknown.
Aim: To understand primary care service use and costs among individuals with dementia in the last year of life, and its association with multiple emergency hospital admissions in last 90 days of life.
Methods: Retrospective cohort study using CPRD dataset linked to HES and ONS data. Individuals with dementia who died between 2009-2019 will be included. The primary outcome is multiple emergency admissions to hospital in the last 90 days of life, an established Quality Indicator for dementia care. The number of face-to-face, telephone and home visit contacts with GP and nurses at the practice, as well as the Continuity of Care index, will be extracted from CPRD. Demographics variables (age, gender, marital status and socioeconomic position), illness-related variables (comorbidities, frailty index) and environmental variables (rate of nursing and care homes beds in CCG) will be included as covariables. A multilevel logistic regression will be used to explore association between primary care contacts and multiple hospital admissions in the last 90 days of life.
The primary outcome will be multiple emergency admissions to hospital in the last 90 days of life, defined based on the work of Gozalo et al. as either more than two emergency hospitalizations for any reason or more than one hospitalization for pneumonia, urinary tract infection, dehydration or sepsis in the last 90 days of life.(1) Emergency admissions will be identified through the Hospital Episodes Statistic (HES) in-patients codes using the spell start date and admission method (See Appendix 2 for codes details).
Katherine Sleeman - Chief Investigator - King's College London (KCL)
Javiera Leniz Martelli - Corresponding Applicant - King's College London (KCL)
Deokhee Yi - Collaborator - King's College London (KCL)
Emeka Chukwusa - Collaborator - King's College London (KCL)
Irene Higginson - Collaborator - King's College London (KCL)
Martin Gulliford - Collaborator - King's College London (KCL)
Sabrina Bajwah - Collaborator - King's College London (KCL)
2011 Rural-Urban Classification at LSOA level;HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation