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Age and Ageing Advance Access originally published online on March 12, 2008
Age and Ageing 2008 37(3):339-342; doi:10.1093/ageing/afn049
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Copyright © The Author 2008. Published by Oxford University Press on behalf of the British Geriatrics Society.

Predicting length of hospitalisation of elderly patients, using the Barthel Index

SIR— Short-stay units (SSUs) are an effective and safe alternative to standard inpatient hospitalisation and have managed to reduce length of stay (LOS) among patients who require admission but not to a specialised unit [1, 2]. The average stay must be 4–5 days, so strict admission criteria must be applied [2–4]. Patient age is one of many factors that influence LOS. Elderly patients may also have a lower functional status before illness that warrant admission. We hypothesise that the previous functional status could affect the LOS. Moreover, in-hospital admission is associated with deterioration of previous functional status, and the lack of autonomy could be an inconvenience in accepting discharge.

The Barthel Index (BI) score has proved most useful in patients with stroke [5] and is also recommended in assessing functional status in elderly patients [6]. This study aims to evaluate the influence of functional status prior to admission, as assessed by the BI, on the LOS of patients over age 65 years admitted to an SSU, and determine whether the BI is better at predicting LOS in a certain pathology group.

Methods

A prospective study was carried out on patients over age 65 years who were admitted to a SSU of Hospital del Mar, Barcelona, Spain, during two consecutive four-month winter periods (from December 2004 to March 2005, and December 2005 to March 2006) and discharged from the unit to their regular homes. Age, sex, type of pathology, LOS and readmission rate at 3, 7 and 30 days after discharge were recorded.

The BI was used to determine the patients' functional capacity prior to admission. The BI uses a scale of 0–100 to rate the degree of independence in activities of daily living, where 0 is total dependence, and 100 is total independence. There are three categories of functional impairment using the following cut-off values: severe (0–50), moderate (51–75), and mild to no impairment (76–100). BI was obtained from standardised interviews with patients and surrogate respondents in some cases.

The patients were divided into two groups. Group 1 included patients with moderate to severe disability (BI 0–75), and Group 2 included patients with mild to no impairment (BI 76–100). The LOS and readmission rates were compared.

The pathology types were divided into six sub-groups: patients with acute exacerbation of chronic pulmonary disease (AECPD), such as chronic obstructive pulmonary disease (COPD), chronic asthma or bronchiectasis; patients with acute pulmonary disease, such as acute bronchitis and pneumonia; patients with heart failure; patients with both AECPD and heart failure; patients with acute pulmonary disease and heart disease; and patients with miscellaneous diseases, such as hyponatremia, renal insufficiency and acute gastroenteritis. The influence of the BI on the LOS and on the readmission rate was assessed for each sub-group.

The statistical study was carried out using the SPSS 12.0. An exploratory multivariate linear regression analysis was performed to determine which factors influence the LOS. The t-test was used to compare averages, and the chi-square test was used to compare proportions. The results are expressed as mean (SD) and percentage. Values of P< 0.05 were considered significant. Multivariate logistic regression was used for identified factors that predict LOS ≥5 days. The strengths of associations of the predictors were expressed as the odds ratio (OR) and a 95% confidence interval (CI).

Results

During the study period, the unit admitted a total of 510 patients, of whom 421 were over the age of 65 years. Thirty patients transferred to another department, and six patients who died were excluded. Ultimately, 385 patients were included: 142 in Group 1 and 243 in Group 2.

LOS of the patients in Group 1 was significantly higher than Group 2 [5.01 (2.6) versus 4.38 (2.3) days; P = 0.016]. Separate analyses by sexes showed that these differences held true for male patients [4.77 (2.5) versus 4.05 (1.7); P = 0.05] but not for female patients [5.18 (2.7) versus 4.74 (2.7); P = ns] (Figure 1). The readmission rates were similar in the two groups.


Figure 1
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  		Figure 1. Comparison of length of stay between groups. Analysis separated by sex show significant differences in men, but not in women. *P = 0.016; **P = 0.05.

 
The influence of the BI on the average LOS was also evaluated for the six pathology types. Table 1 shows the break-up of the number of patients under type of pathology, LOS, and BI. Only patients with AECPD showed a difference in LOS based on the BI score [5.93 (2.7) versus 4.29 (2.3); P < 0.001]. Other types of pathologies did not show statistical significance. Assessing by sex, the differences held true for male patients [5.52 (2.6) versus 3.91 (1.7); P = 0.006] but not for female patients [6.42 (2.8) versus 5.15 (3.2); P = ns]. The analysed sub-groups showed no differences in readmission rates.


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  		Table 1. Length of stay by type of pathology and Barthel Index

 
The multivariate linear regression analysis showed that sex and BI influenced the LOS, while age had no influence. For patients with a BI >75, the average stay dropped by 0.63 days. For patients with a given BI, the average stay increased by 0.6 days if the patient was female. The AECPD sub-group showed that the differences in LOS were dependent on BI score and sex. The patients with a BI > 75 had an average stay 1.47 days shorter than the patients with a BI ≤75 and, for a given score, the LOS was 1.13 days longer in female patients.

The significant predictors on multivariate logistic regression analysis of LOS ≥5 days were a BI ≤75 (OR = 2.49; 95% CI 1.50–4.13); female sex (OR = 2.10; 95% CI 1.29–3.43) and AECPD (OR = 1.67; 95% CI 1.04–2.78).

Discussion

When deciding on the time to admit an elderly patient in a SSU, physicians have to consider clinical and prognostic criteria, and conditions associated with ageing. We would assess if prior functional status, evaluated with BI score, could be an additional tool, to decide admission in a SSU, or in a conventional unit.

The results show that a BI score > 75 is useful for predicting LOS of male patients with AEPCD requiring admission to a SSU. Consistent with these results, BI ≤75, female sex and AEPCD were significant predictors of LOS ≥ 5 days in our study. Age did not have any influence on LOS. The BI was not found to be useful in female patients or for any other pathology analysed. This could be explained due to a small number of patients included in another sub-group. We think that difference on LOS between men and women on AECPD group could be explained because, in our country, in general, women are better carers of their husbands than men of their wives. This could influence physicians at the time of discharge. Sex differences in another sub-group were not analysed because we found no differences associated with BI score. We used a BI score of 75 like a limit between mild or no disability, and moderate or severe disability. In the literature, a standard score does not exist to define all types of disabilities [7–9]. However, a cut-off to 75 has been used in previous studies [9].

In several studies, the BI has proved to be a good predictor of in-hospital mortality [10, 11], out-of-hospital mortality [12], and discharge to a long-term facility or a hospital stay of over 90 days [11]. The BI was also found to be a predicting factor for LOS in unselected patients over the age of 65 years [10]. The second study found that the patients over age 65 years had a longer LOS than those aged 65 years or less, and that the BI was a protective factor for discharge to a long-term facility [11], but it provided no data on the influence of the BI on the overall LOS. In the third study, the BI did not influence the average stay of patients over the age of 65 years with pneumonia [12]. Because these studies were carried out in conventional hospital units [10, 12] and an intermediate care unit [11], their results cannot be extrapolated to SSUs. Nevertheless, like Campbell et al. [10], we found that the BI influences the average stay of at least a selected sub-group of patients over age 65 years: male patients with AECPD. Finally, in another recent study, no differences in BI scores and LOS were found between patients with COPD exacerbations with congestive heart failure [13]. We found that LOS was influenced by the BI in patients with chronic pulmonary disease but not in patients with congestive heart failure. These differences may be due to the fact that all of the patients in the study of Formiga et al. [13] were non-agenarians, so age may have played a greater role in our study.

BI scores are known to be lower in chronic pulmonary patients than in control patients [14]. However, the FEV1 did not by itself determine LOS on patients admitted in a SSU [15].

The potential limitations of this study were the small number of cases in the non-AECPD sub-groups, and the fact that comorbidities and discharge destination were not assessed. Further studies are needed to clarify these points.

In short, in male patients requiring admission to an SSU due to AECPD, the BI could enhance decisions regarding admission to these units.

Key points

  • The aim of this study is to identify factors that influence LOS of old patients admitted in a SSU.
  • The factors that influenced LOS were sex and BI.
  • A BI score of 75 increased LOS by 0.68 days, and LOS increased by 0.6 days if the patient was female.
  • Differences on LOS according to BI occurred only in male patients.
  • An analysis of pathology types showed that only AECPD sub-group exhibited differences in LOS as a function of BI.
  • Significant predictors of LOS equal to or greater than 5 days were a BI score of 75, female sex and AECPD.

Conflicts of interest

None declared.

Acknowledgements

To Mark Lodge for editorial assistance, and to Josep M. Manresa, from Asessorament Metodològic en Investigació Biomédica (AMIB), IMIM, for statistical analysis.

August Supervía*, Dolors Aranda, Miguel Angel Márquez, Alfons Aguirre, Elias Skaf and Juan Gutiérrez

Department of Emergency, Hospital del Mar, Passeig Marítim 25-29, 08003 Barcelona, Spain

* To whom correspondence should be addressed Email: Asupervia{at}imas.imim.es

References

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  2. Corbella X, Salazar A, Maiques JM, et al. Unidad de corta estancia de urgencias como alternativa a la hospitalización convencional. Med Clin (Barc) (2002) 118:515.[Medline]
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  8. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel index for stroke rehabilitation. J Clin Epidemiol (1989) 42:703–9.[CrossRef][Web of Science][Medline]
  9. Saxena SK, Ng TP, Yong D, et al. Total direct cost, length of hospital stay, institutional discharges and their determinants from rehabilitation settings in stroke patients. Acta Neurol Scand (2006) 114:307–14.[CrossRef][Web of Science][Medline]
  10. Campbell SE, Seymour DG, Primrose WR, et al. A multi-centre European study of factors affecting the discharge destination of older people admitted to hospital: analysis of in-hospital data from the ACMEplus project. Age Ageing (2005) 34:467–75.[Abstract/Free Full Text]
  11. Torres OH, Francia E, Longobardi V, et al. Short- and long-term outcomes of older patients in intermediate care units. Intensive Care Med (2006) 32:1052–9.[CrossRef][Web of Science][Medline]
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  13. Formiga F, López-Soto A, Masanés F, et al. Influence of acute exacerbation of chronic obstructive pulmonary disease or congestive heart failure on functional decline after hospitalization in nonagenarian patients. Eur J Intern Med (2005) 16:24–8.[CrossRef][Medline]
  14. Peruzza S, Sergi S, Vianello A, et al. Chronic obstructive pulmonary disease (COPD) in elderly subjects: impact on functional status and quality of life. Respir Med (2003) 97:612–7.[CrossRef][Web of Science][Medline]
  15. De la Iglesia F, Valiño P, Pita S, et al. Factors predicting a hospital stay of over 3 days in patients with acute exacerbation of chronic obstructive pulmonary disease. J Intern Med (2002) 251:500–7.[CrossRef][Web of Science][Medline]

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