No abstract

Managing patients with multimorbidity and frequent hospital readmissions is a challenge. Integrated care programs that consider their needs and allow for personalized care are necessary for their early identification and management. This work aims to describe these patients' clinical characteristics and evaluate a program designed to reducing readmissions. This prospective study analyzed all patients with ≥ 3 admissions to a medical department in the previous year who were included in the Internal Medicine Department chronic care program at the Lucus Augusti University Hospital (Lugo, Spain) between April 1, 2019 and April 30, 2021. A multidimensional assessment, personalized care plan, and proactive follow-up with a case manager nurse were provided via an advanced hospital system. Clinical and demographic variables and data on healthcare system use were analyzed at 6 and 12 months before and after inclusion. Descriptive and survival analyses were performed. One hundred sixty-one patients were included. Program participants were elderly (mean 81.4 (SD 11) years), had multimorbidity (10.2 (3) chronic diseases) and polypharmacy (10.6 (3.5) drugs), frequently used the healthcare system, and were highly complex. Most were included for heart failure. The program led to significant reductions in admissions and emergency department visits (p = .0001). A total of 44.7% patients died within 1 year. The PROFUND Index showed good predictive ability (p = .013), with high values associated with mortality (RR 1.15, p = .001). Patients with frequent hospital readmissions are highly complex and need special care. A personalized integrated care program reduced admissions and allowed for individualized decision-making.

ResumenObjetivo: Describir la tendencia temporal y el perfil clínico de los centenarios que ingresan en los hospitales gallegos. Método: Análisis del Registro de Altas del Sistema Nacional de Salud en el periodo 2004 -2013. Resultados: Se registraron 1.373 ingresos, con una edad media de 101,2±1,4. El 73,7% fueron mujeres. El número de ingresos por año se incrementó con el tiempo (0,31% de los ingresos en 2004 versus 0,69% en 2013). Ourense y Lugo fueron las provincias donde hubo más ingresos en proporción con la población atendida. Más de la mitad de los pacientes fueron atendidos por los Servicios de Medicina Interna. Los centenarios ingresaron a través de Servicio de Urgencias, y el motivo de ingreso fue médico en el 84,7%, constituyendo el GRD (Grupos relacionados por el diagnóstico) más frecuente las infecciones respiratorias. En los varones hubo una mayor incidencia de enfermedades respiratorias, mientras que las mujeres presentaron mayor incidencia de fracturas de cadera. La estancia media fue de 8,6±7 días, alcanzando una mortalidad de casi el 30% y la tasa de reingresos al año fue del 7,8%. Conclusiones: Se observa un incremento progresivo del número de ingresos de pacientes centenarios en los últimos años, fundamentalmente por patología médica. Presentan una mortalidad elevada y reingresan con frecuencia. Palabras clave: centenarios, epidemiologia, ingreso hospitalario. Internal Medicine Services attended more than half of patients. Centenarians were admitted through the emergency department, and the reason for admission was medical in 84.7%, being the most frequent DRG (Diagnosis-Related Group) respiratory infections. There was a higher incidence of respiratory diseases in males, while women had a higher incidence of hip fractures. The mean length of stay was 8.6 ± 7 days, with a mortality of almost 30%. The readmission rate was 7.8%. Conclusions: There is a progressive increase in the number of centenarians admissions in the lasts years, mainly due to medical conditions. They have a high mortality and are frequently readmitted.