Do rates of hospital admission for falls and hip fracture in elderly people vary by socio-economic status?

OBJECTIVE: To determine the relationship between hospital admissions for falls and hip fracture in elderly people and area characteristics such as socio-economic deprivation. STUDY DESIGN: Ecological study of routinely collected hospital admissions data for falls and hip fracture in people aged 75 years or over for 1992-1997, linked at electoral ward level with characteristics from census data. METHODS: In total, 42,293 and 17,390 admissions were identified for falls and hip fracture, respectively, from 858 electoral wards in Trent. Rate ratios (RRs) for hospital admissions for falls and hip fracture were calculated by the electoral wards' Townsend score divided by quintiles. RRs were estimated by negative binomial regression and adjusted for the ward characteristics of age, gender, ethnicity, rurality, proportion of elderly people living alone and distance from hospital. RESULTS: There was a small but statistically significant association at electoral ward level between hospital admissions for falls and the Townsend score, with the most deprived wards having a 10% higher admission rate for falls compared with the most affluent wards (adjusted RR 1.10, 95% CI 1.01-1.19). No association was found between hospital admission for hip fracture and deprivation (adjusted RR 1.05, 95% CI 0.95-1.16). CONCLUSION: There is some evidence of an association at electoral ward level between hospital admissions for falls and socio-economic deprivation, with higher rates in deprived areas. No such association was found for hip fracture. Further work is required to assess the impact of interventions on reducing inequalities in hospital admission rates for falls in elderly people.

The impact of nursing home patients on prescribing costs in general practice.

OBJECTIVES: To compare the costs of prescribing for older people in nursing homes with older people living at home and to compare patterns of prescribing between these two groups. DESIGN: Retrospective case-control study. SETTING: Nine general practices in Nottinghamshire. SUBJECTS: Two hundred and seventy patients aged 65 years and over living in nursing homes matched for age, sex and general practice, with 270 patients living in their own homes. MAIN OUTCOME MEASURES: A comparison of the costs of prescriptions, the number of items on prescription and the types of drugs prescribed between the cases and controls. RESULTS: The mean cost of prescriptions per patient month was almost three times higher for nursing home patients than controls (45.27 pounds compared to 16.46 pounds). The mean number of items prescribed per patient month was also higher in nursing home patients (5.60 compared to 2.55). Total costs of prescriptions for nursing home patients were higher than for controls (P < 0.0001), as were total numbers of prescription items (P < 0.001). There were differences in the types of medication prescribed between the two groups, including considerably higher costs for central nervous system drugs, ulcer healing drugs, laxatives and enteral nutrition in nursing home residents. CONCLUSIONS: When calculating general practice prescribing budgets, nursing home patients should have a greater weighting than other patients of similar age and sex.

Relation of out of hours activity by general practice and accident and emergency services with deprivation in Nottingham: longitudinal survey.

OBJECTIVES: To investigate the relation between out of hours activity of general practice and accident and emergency services with deprivation and distance from accident and emergency department. DESIGN: Six month longitudinal study. SETTING: Six general practices and the sole accident and emergency department in Nottingham. SUBJECTS: 4745 out of hours contacts generated by 45,182 patients from 23 electoral wards registered with six practices. MAIN OUTCOME MEASURES: Rates of out of hours contacts for general practice and accident and emergency services calculated by electoral ward; Jarman and Townsend deprivation scores and distance from accident and emergency department of electoral wards. RESULTS: Distances of wards from accident and emergency department ranged from 0.8 to 9 km, and Jarman deprivation scores ranged from -23.4 to 51.8. Out of hours contacts varied by ward from 110 to 350 events/1000 patients/year, and 58% of this variation was explained by the Jarman score. General practice and accident and emergency rates were positively correlated (Pearson coefficient 0.50, P = 0.015). Proximity to accident and emergency department was not significantly associated with increased activity when deprivation was included in regression analysis. One practice had substantially higher out of hours activity (B coefficient 124 (95% confidence interval 67 to 181)) even when deprivation was included in regression analysis. CONCLUSIONS: A disproportionate amount of out of hours workload fell on deprived inner city practices. High general practice and high accident and emergency activity occurred in the same areas rather than one service substituting for the other.

Characteristics of patients aged 75 years and over who are discharged from hospital without district nursing support.

To investigate the state of health and needs of over-75-year-olds discharged from hospital and not referred to the District Nurse Service, patients in this age group who were discharged from hospital, who returned to their own or a relative's home and were not referred to the District Nurse Service were interviewed by Health Visitors during their normal post-discharge visit. Assessment was by a questionnaire on details of discharge, statutory, voluntary and informal support, physical status, disability level, ability to self-care and mental status. It was found that there was wide variation in timing of Health Visitors' post-discharge visits, and most patients had had some contact with their GP before this visit. Almost half the patients were discharged from General Surgery or surgical specialties. Most patients were fairly healthy but a minority had severe disabilities. Physical status, disability level and ability to self-care were related to age and sex of the patient, with older patients and women having poorer health status. Women had poorer mental status than men. It is concluded that the wide variety in health status and needs of this group of patients suggest that they should be taken into account in the planning of new discharge procedures. Closer links between the hospital, community teams and general practice are suggested.

The care of people over 75 years old after discharge from hospital: an evaluation of timetabled visiting by Health Visitor Assistants.

The objective of this study was to evaluate a programme of timetabled visiting by Health Visitor Assistants (HVAs) to patients over 75 years old who were recently discharged from hospital. An outcome evaluation examined whether patients benefited in measured health status and use of services over the year of the programme. A randomly selected group of patients (the intervention group) who were allocated to the programme of visiting were compared with an equal-sized randomly selected group of patients (the control group) who had no timetabled visiting. A process evaluation examined the actions taken by HVAs during their visits and related the actions taken to patients' measured health status and other characteristics. No overall benefit from the programme of visiting was found in the outcome evaluation. There was wide variation in the numbers of actions recorded for different patients. Numbers of HVAs' actions were related to patient's health status and sex, with more actions being initiated for those in poorer health and women. Neither age nor whether the patient lived alone were found to be related to numbers of HVAs' actions. It was concluded that the lack of demonstrated overall benefit and the wide variation in actions taken on patients' behalf suggest that this type of service cannot be recommended for all discharged patients over 75 years. Poor health at the time of discharge is recommended as a first choice of measure for need of support. Exchange of information between general practice and hospital about previous dependency may aid the identification of patients who need post-discharge support.