Our survey results describe an elderly rural group of patients with multiple hospital admissions for chronic disease. This group had high rates of comorbidity and a large proportion entered aged care or died within the study period. The group were predominantly of lower socio-economic status, and social isolation and psychological distress were common. Factors significantly associated with more frequent admission (4+ admissions compared to 3 admissions) were a diagnosis of CHF, a lower social network score i.e. respondents with smaller social networks and with less social contact, and a higher Charlson Comorbidity Index score. All patients in the invited group had a GP and our results suggest that at least from the patients’ perspectives their hospital admissions were appropriate and unavoidable on the day. Fewer than half our respondents had a written GP care plan.
Significantly fewer of our survey respondents rated their general health as good or better compared to the North Coast population aged 75 and over  (32% vs 72% p<0.001). Generally, respondents were of low socio-economic status which is consistent with the literature [16, 40]. Most respondents were on a pension (81%) and this rate is significantly higher (p=0.001) than for the 65+ population in the North Coast Area Health Service area in 2009 (69%) . Nearly one quarter (22%) of respondents reported difficulty affording their medication with important implications for the treatment of their condition and for avoiding hospital admission.
We anticipated that medication would be an important factor in frequent hospitalisation for this group based on the literature [41–43] and previous work by our group . One third (34%) of the invited group (n=512) were using five or more medications (defined as ‘polypharmacy’ by Linjakumpu et al. ), the complexity of which may lead to interactions and/or medicine mismanagement. Nearly a quarter of men reported ever having forgotten to take their medication. Interestingly, men with a Webster pack reported forgetting more than men without a Webster pack (34.8% vs 16.2%). This may be because those who were having difficulty remembering their medications were more likely to be offered these packs. Interventions such as the Home Medicines Review (HMR), conducted in the community in Australia, have been shown to be effective at reducing potentially inappropriate medicines in older age groups , which might lead to hospitalisation. Greater access to HMR in rural areas via GPs (particularly given this patient group appear to have GPs) might make a contribution to improving individual medication management, although access to pharmacists in rural areas can be problematic, and increased access to HMRs does not address the issue of affordable medication. We had no evidence of the utilisation rates of HMR in our respondents.
Social isolation was an important factor for many of our respondents. We were not able to explore social isolation in non-respondents as it is not routinely collected in hospital admission data. One third (34%) of respondents lived alone (more commonly women). This is significantly higher (p=0.018) than in the general population where 25% of older people (60+) in NSW live alone . The social network scores amongst our respondents indicated greater social isolation than in a recent study of Australian women 70–85 years who had experienced a major illness in the last 12 months, or who had a probable psychiatric condition . One quarter (25%) of respondents spent no time with friends/family they didn’t live with in the previous week. Of the 35 respondents who lived alone, six of these (all men), had no social contact with friends/family nor attended meetings or clubs (their median Dukes network score was 6) in the previous week. Consistent with other studies , the least socially isolated respondents were women living alone. Previous work has shown social isolation associated with poor health, depression and loss of confidence . A recent qualitative study reported that fifty six out of one hundred elderly people interviewed who presented to an Australian city public hospital emergency department reported feeling socially disconnected . Our own qualitative study with a broad range of community-based health and support service providers suggested that social isolation was a key factor contributing to frequent and/or avoidable hospital admissions amongst older patients with chronic disease . This is supported by the finding that among survey respondents, greater social isolation was associated with having more frequent admissions (4+ admissions). The possible complex mechanisms whereby social isolation might contribute to admission in older rural patients with chronic disease, for example social isolation leading to depression leading to lack of motivation for self-management, are discussed in our paper on this topic .
A number of related social factors were identified which may be contributing to the high use of hospital services. Nearly one third of respondents reported having no car they could drive and of those living alone, 29% had no car access. This has implications not only for exacerbating their social isolation but also for accessing services in rural Australia where public transport is limited or non-existent, if they have no friends or family to take them. One in five (22%) of respondents who reported needing regular help with daily tasks e.g. personal care, did not have either a close friend or relative who regularly cared for them. While these patients may have obtained carer support from community or social services, a degree of unmet need is likely to be present.
There are a number of community based services which might partially ameliorate the impact of social isolation including valuable community transport initiatives, however, many of these services have been reduced in recent years e.g. services which used to offer accompanied shopping trips now only offer unaccompanied shopping . These services often have long waiting lists and there are often considerable additional barriers to accessing services, sometimes specific to rural locations [51, 52]. Increasing this provision and access to it, may present an opportunity to impact on social isolation which may in turn affect hospital admission amongst this patient group.
Over half the respondents (53%) had mild, moderate or severe psychological distress (scoring over 15 on the K10 assessment). With 60% of those aged 65–74 years and 46% of those 75 or older experiencing psychological distress. This is significantly higher than for the corresponding age groups in the general Australian population (25%, p<0.001; and 29%, p<0.001, respectively) . This finding points to possibly undiagnosed psychological distress amongst this group. Psychological distress may contribute to hospitalisation through poor chronic disease management due to low incentive and energy to self-manage [54, 55]. This suggests that improved GP attention to the mental health status of patients with chronic disease and a history of frequent admission might be beneficial in both diagnosing and treating mental health disorders, as well as activating self-management . However, the majority of survey respondents rated their self-management as reasonably good.
While all the study population were registered with a GP, we had no information on the nature or frequency of contact with their GP. Only one in three (34%) survey respondents recalled receiving regular reminders to visit the GP, and only 38% reported having a written care plan. Our study population is composed of the type of patient for whom care plans are thought to be particularly beneficial. This suggests a failure of delivery of best practice in primary care amongst this group which could possibly be improved and warrants further exploration.
In our study population COPD and coronary artery disease were the most common primary diagnoses. A higher Charlson Comorbidity Index score was associated with more frequent admission, as was congestive heart failure. Given that congestive heart failure is characterised by progressive deterioration, frequent hospitalisation and requires complex self-management, this is not surprising . An ethnographic study of self-management by people with diabetes has described the difficult balancing act required, and that capacity to self-manage was limited for some people by their co-morbidity, psychological factors and social capital, all issues among our population . While the specifics of self-management for diabetes are different to those for heart failure, they are similarly complex, require close self-monitoring, careful attention to diet and medications, and impose important social restrictions. In North Coast NSW there is a well-established and regarded Heart Failure Program, and evidence exists demonstrating that programs for CHF can reduce hospitalisation in the short term amongst specific groups . However, difficulties with these kinds of programs relate to access, particularly in rural areas, and ‘maintenance’, a crucial factor with all chronic disease but particularly with CHF. Programs run for a finite timeframe of a few weeks of contact per patient, whereas many patients require longer-term regular on-going support to sustain their motivation and capacity for modifying health behaviours (for example monitoring fluid intake), and/or to account for the fact that these patients often have poor short-term memory and some dementia .
The high mortality amongst this group represents a significant study challenge. In our study nearly one in five (n= 136, 19%) patients of the initially identified 709 were known to have died within 2 and one half years (between July 2008 and January 2011). Since the commencement of the Connecting Care Program (and the identification of our study population) the eligibility criteria for the Program has been amended to identify patients at the hospital when they are admitted rather than retrospectively (as was the case in this cohort), to include patients of all ages and to lower the threshold of multiple admissions from the 3 plus used initially . This will likely target patients less ill than those in the study population we report in this paper, and may extend the scope for improving disease management and thus reduce future potentially avoidable admissions.
Given the level of morbidity of respondents, and that some patients had been “coached” to present to the Emergency Department under particular circumstances, it is unsurprising that the majority reported admissions as appropriate on the day, that is, from the patient’s perspective the admission could not have been avoided on that day. This highlights the difficulties of using ACS admissions as a proxy measure for “avoidability”.
Whilst our telephone follow-up focused on appropriateness of admission on the day, we also obtained a small number of unprompted narratives around potential longer-term avoidability of admission. These included medication issues and anxiety, and health behaviours such as not following ‘doctors orders’ or physical over-exertion, although no strong themes emerged from this limited information. Future work should include an exploration of avoidability in the weeks and months leading up to a specific admission, and investigate the decision-making process which leads patients to call for an ambulance , to ensure the patient and clinician perspective of potential avoidability of hospitalisation is adequately captured.
We anticipated that the study population would be difficult to engage in a written survey due to their age and morbidity. While only one quarter (24%) of those invited consented to participate in the study, a high proportion of consenters completed the survey questionnaire (105/122 86%) with only nine patients not responding. Two consenting patients died before completing the questionnaire and six patients withdrew from the study after consenting mainly due to deteriorating health, reinforcing our experience of this group as vulnerable and sick.
A number of mechanisms were employed to maximize the survey response rate including personalising letters, providing a return envelope and follow up telephone contact . We also used coloured paper and photographs of two of the research team on the front cover of the questionnaire and anecdotal evidence from contact with patients suggested that these two elements improved the response.
The higher proportion of men who completed the survey is unexpected from other general household survey research using postal questionnaires  but is similar to findings from previous surveys amongst older patients with chronic disease .
Our respondents were younger, and were less sick (they had significantly fewer unplanned admissions and shorter stays in hospital) than non-respondents. Non-response has previously been associated with morbidity, age, and with living alone [61, 62]. Although the generalizability of our survey results to the larger study population is limited by the low response rate and restricted sample size, it is likely that our results offer a conservative picture of the study population, and that the potentially unmet needs in the respondent group apply to the non-respondent group. We acknowledge that the invited group were selected from the public hospital system, thus presenting a potentially biased picture of older people with chronic conditions and a history of frequent admission. However, our understanding is that private hospitals in the region rarely deal with unplanned hospital admission which was the focus of our study.
Cross-sectional surveys are limited by capturing only a moment in time, and our understanding of causal associations is limited by reverse causality, a feature of this type of study design. Surveys restrict the information respondents provide, by what they do not include, and by nuance of interpretation by respondents. Some of these limitations were redressed by the telephone follow up that we conducted. As this was a preliminary study, our intention in future work is to conduct more robust and in-depth qualitative work with this patient group to ensure the patient perspective is fully captured.
We assumed that the level of cognitive impairment in our respondent group would be less than in our non-respondent group, but had no means of assessing this. If this was the case, the implications of our work, particularly for self-management (including medications management), would be magnified amongst the non-respondent group. Finally, a major limitation of our study was that the small sample size of the survey respondents limited our ability to detect any but large differences between sub-groups.