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Discharge delays may be cause of sharp rise in deaths in the UK

The increased prevalence delays in discharge from hospital was associated with the sharp rise in mortality in England in 2015, accounting for up to a fifth of mortality increases.

UK researchers believe they have found evidence that poorer performance by the National Health Service (NHS) and adult social care services as a result of austerity may be having an adverse impact on the population’s health.

Between July 2014 and June 2015, England and Wales saw an additional 39,074 deaths compared with the same period the previous year. Despite mortality rates fluctuating every year, this was the largest rise for nearly 50 years in England, and the higher rate of mortality has remained throughout 2016 and into 2017. Most of these additional deaths were in frail, older individuals.

During the same period, there have been funding issues, with the number of NHS trusts amassing budget deficits increasing sharply since 2014-2015, alongside rising waiting periods for elective surgery in 2015. Issues within the NHS appear to have been made worse by problems with the provision of adult social care to support individuals who are leaving NHS care and the pressures of increased demand.

Researchers from Liverpool University, Oxford University, Glasgow University and York University set out to examine whether these increases in individuals delayed from being discharged from hospital were associated with changes in the number of deaths. They theorised that delayed discharges could be an indicator of worsening health and social care, which could influence mortality rates through delaying transfer to appropriate care and/or preventing new patients from accessing appropriate care.

They used Office for National Statistics data on the number of deaths and calculated monthly mortality rates for England for the period August 2010 to March 2016. They then compared the mortality rates with delays in discharges from NHS England data on transfers of care for acute and non-acute patients in England.

Results showed that from 2011, there was an upward trend in the total number of days that acute patients experienced delays in their discharges, although not for the total number of acute patients being delayed. The rate of this increase appeared to change in 2014, where both measures began to show an upwards trend. The trend for non-acute admissions differed with a ‘u’-shaped trend of declines up to 2014 and increases after for both measures.

The researchers estimated that each additional day that an acute admission was late being discharged was associated with an increase in 0.39 deaths. For each additional acute patient delayed being discharged, they found an increase of 7.32 deaths. Findings for non-acute admissions were mixed.

The authors acknowledge several limitations, such as the fact that their analyses were only observational and associational, so were limited in their ability to draw out exact causes. Also, by using population-level data, they could not detect whether or not delayed discharges for particular individuals actually led to deaths.

Their findings, therefore, should be interpreted cautiously, but nevertheless, they say it provides a useful starting point for further analysis. They say: “In conclusion, we have shown that the increasing prevalence of delayed discharges within hospitals occurred as mortality rates rose in England.

“Despite the exploratory nature of our study, the implications of our findings are important and require urgent attention. Greater investment in the NHS and adult social care to address the rising levels of delayed discharges may be needed to tackle the rapid rise in mortality rates.”

Dr Mark Green at the University of Liverpool said: “Since 2014, the number of patients admitted for acute conditions who were delayed being discharged from hospital have has almost increased by 50%. This creates blockages in the NHS where beds are not available for new patients, and since these individuals are being admitted for acute and often pressing issues any delay to accessing services can be deadly. It is clear that increased funding to both the NHS and adult social care to minimise issues with discharged patients would benefit the population widely.”

Abstract
Background: 2015 saw the largest annual spike of mortality rates in England in almost 50 years. We examine whether these changes in mortality rates are associated with an indicator of poor functioning of health and social care: delay in hospital discharges.
Methods: Office for National Statistics monthly data of death counts and mortality rates for the period August 2010–March 2016 were compared with delays in discharges from National Health Service (NHS) England data on transfers of care for acute and non-acute patients in England. Autoregressive Integrated Moving Average regression models were used in the analysis.
Results: We estimate that each additional day an acute admission was late being discharged was associated with an increase in 0.394 deaths (95% CIs 0.220 to 0.569). For each additional acute patient delayed being discharged, we found an increase of 7.322 deaths (95% CIs 1.754 to 12.890). Findings for non-acute admissions were mixed.
Conclusion: The increased prevalence of patients being delayed in discharge from hospital in 2015 was associated with increases in mortality, accounting for up to a fifth of mortality increases. Our study provides evidence that a lower quality of performance of the NHS and adult social care as a result of austerity may be having an adverse impact on population health.

Authors
Mark A Green, Danny Dorling, Jonathan Minton, Kate E Pickett

[link url="http://www.bmj.com/company/newsroom/delayed-hospital-discharges-could-be-linked-to-rise-in-population-deaths/"]BMJ material[/link]
[link url="http://jech.bmj.com/content/early/2017/09/01/jech-2017-209403"]Journal of Epidemiology & Community Health abstract[/link]

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