Project

Discipline

medical care; place of death; end-of-life; resource use; multimorbidity

Lead
Das Risiko einer medizinischen Überversorgung ist bei mehrfach erkrankten Betagten hoch. Das Projekt erforscht die Einflussfaktoren, welche die Wege betagter Patienten durch die Krankenhäuser und Krankenheime der Schweiz am Lebensende bestimmen.
Lay summary
Hintergrund Der medizinische Fortschritt und die Alterung der Bevölkerung führten in den letzten Jahrzehnten dazu, dass immer mehr Betagte unter mehreren, oft chronischen Krankheiten gleichzeitig leiden. Solche Mehrfacherkrankungen führen oft zu einer intensiven medizinischen Betreuung, vielfach durch mehrere, auf die einzelnen Leiden spezialisierte Ärzte und Ärztinnen. Manchmal sind solche medizinischen Massnahmen weder von den Patienten noch von ihren Angehörigen erwünscht, gelegentlich sind sie medizinisch wenig sinnvoll. Zusätzlich entstehen unnötige Gesundheitskosten. Ziel Das Studienteam erforscht, wie viel Zeit betagte Menschen am Lebensende in Krankenhäusern und -heimen verbringen, wie intensiv sie medizinisch betreut werden, wo sie sterben und welche regionalen, kulturellen, sozialen, ökonomischen und medizinischen Faktoren ihren Weg durch die medizinischen Institutionen bestimmen. Das Team verknüpft drei schweizerische Datenbanken: die schweizerische Nationalkohorte, die medizinische Statistik der Krankenhäuser und die Statistik der sozialmedizinischen Institutionen. Dadurch entsteht die Möglichkeit, den Weg eines Individuums durch die medizinischen Institutionen während seiner letzten Lebensjahre zu verfolgen und den Zusammenhang dieses Wegs mit den regionalen, kulturellen und anderen Faktoren zu untersuchen. Bedeutung Die Erkenntnisse des Projekts können bei der Anpassung des Gesundheitssystems an die Bedürfnisse der Sterbenden und ihrer Familienangehörigen behilflich sein. Zusätzlich können die Ergebnisse bei der Debatte um eine sinnvolle Verteilung medizinischer Ressourcen von Nutzen sein.

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Last update: 18.06.2013

Lead
Le risque de prise en charge médicale excessive est élevé chez les personnes âgées atteintes de plusieurs maladies. Le projet étudie les facteurs qui déterminent les chemins cliniques que suivent les patients âgés en fin de vie à travers les hôpitaux et les établissements médico-sociaux en Suisse.
Lay summary
Contexte Le progrès médical et le vieillissement de la population ont conduit ces dernières décennies à un nombre croissant de personnes très âgées souffrant simultanément de plusieurs maladies, souvent chroniques. Ces maladies multiples entraînent fréquemment une prise en charge médicale intensive, assurée par plusieurs médecins dont chacun est spécialisé dans une de ces maladies. Il peut arriver que ces traitements médicaux ne soient souhaités ni par le patient, ni par ses proches, voire qu’ils soient peu judicieux du point de vue médical. De plus, ils entraînent des coûts de santé inutiles. But L’équipe de recherche étudie combien de temps les personnes âgées en fin de vie passent à l’hôpital et en EMS, quelle est l’intensité du suivi médical, où ces personnes décèdent et quels sont les facteurs régionaux, culturels, sociaux, économiques et médicaux qui déterminent leurs chemins dans les institutions médicales. L’équipe relie trois banques de données suisses: la Cohorte nationale suisse, la Statistique médicale des hôpitaux et la Statistique des institutions médico-sociales. Ceci permet de suivre le chemin parcouru par un individu à travers les institutions médicales au cours de ses dernières années de vie et d’étudier le rapport entre ce chemin et des facteurs régionaux, culturels ou autres. Portée Les découvertes de ce projet pourront aider à adapter le système de santé aux besoins des mourants et de leurs proches. De plus, les résultats pourront être utiles dans le débat sur une répartition judicieuse des ressources médicales.

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Last update: 18.06.2013

Lead
The risk of overprovision of medical care is high for elderly persons with co-occurrence of illnesses. This study examines the factors that influence elderly patients’ pathways of care at the end of life through the hospitals and nursing homes in Switzerland.
Lay summary
Background Medical advances and the aging of the population in the last decades have resulted in more and more elderly persons with multiple, often chronic illnesses. This multimorbidity often leads to intensive medical care, frequently by several specialists. Sometimes neither the patients nor their family want the medical measures, and occasionally the measures are not medically advisable. In addition, unnecessary health costs are incurred. Aim This study will investigate how much time elderly people at the end of life spend in hospitals and nursing homes, how intensive the medical care that they receive is, where they die, and what regional, cultural, social and economic factors determine their pathways through the medical institutions. The research team will utilise three Swiss databases: the Swiss National Cohort, the hospitals’ medical statistics and the statistics recorded by social-medical institu-tions. This will make it possible to track the paths of individuals through the medical institutions during the last years of their lives and to examine the relationship between these pathways and regional, cultural and other factors. Significance The results of this study can be an aid to adapting the health care system to the needs of the dying and their family members. In addition, the results can be useful in the debate on the sensible distribution of medical resources.

Direct link to Lay Summary

Last update: 18.06.2013

Active participation

Active participation

Self-organised

Acute care hospitals and long-term care facilities have increasingly become places of death for the terminally ill; however, most people prefer to die at home. Due to progress of modern medicine many previously fatal diseases can be treated (but not cured) and are transformed to chronic medical conditions (diseases and impairments) with need for ongoing medical care. Various projections show that within 20 years 50% and more of the population may be living with multimorbidity (defined as co-occurrence of two or more chronic medical conditions in the same person). Multimorbidity is significantly associated with higher mortality, increased disability, decline of functional status, decreased quality of life, and leads to an intensive utilization of health care services. Patients with multimorbidity, especially those near their end-of-life, are a highly vulnerable population to undergo aggressive medical care, even if such care might be unwanted and inappropriate. Given the individual preference for dying at home, the growing population with multimorbidity at high risk for aggressive medical care, and the potential economic implications of institutional dying, we need a better understanding of the determinants of pathways of inpatient care (admissions to acute care hospitals and long-term care facilities) during the last years of life. Knowledge of these determinants (chronic medical conditions and their co-occurrence, socio-demographic characteristics, and information on availability of medical resources) might help to control a further upsurge of medical services provided to the terminally ill.Hitherto, in Switzerland, there are no population based data on the prevalence and duration of inpatient care in acute care hospitals and long-term care facilities during the last years of life. We will congregate these data based on anonymous record linkage using three different data sources: the Swiss Hospital Discharge Statistics (acute care hospitals), the Statistics of the Socio-medical Institutions (long-term care facilities), and the Swiss National Cohort (nationwide data-base combining individual data from the Swiss Census and the Cause of Death Registry). This linkage will enable access to a wealth of socio-demographic and medical information on a nationwide level and will allow a comprehensive analysis of medical and non-medical determinants of the place of death and the patterns of inpatient care at the end-of-life.Part A of our project will focus on medical proximity to death (selected chronic medical conditions and their multiples) and explore the impact of multimorbidity on survival and pathways of inpatient medical care. Study entry will be defined by the first hospitalization with a given multimorbid condition and follow-up will end on the day of death, or will be censored (if the day of death cannot be defined) on the last day of the most recent hospital or long-term care facility discharge.Part B of our project will assess inpatient care during the period preceding death (temporal proximity to death). We will disentangle stays in acute care hospitals and long-term care facilities and analyze determinants of pathways of inpatient care at the end-of-life. The observation period will be defined by the date of death and analyses will be retrospective over the last two years of life.In 2014, we will rebuild our database including recent data years (2009 to 2012) from the three different data sources in order to explore trends over time.This research project will provide substantial novel information on pathways of medical care (use of inpatient services and interaction of hospital and long-term care) in the last years of life, allow exploration of medical, regional and socio-demographic determinants, and help understanding the impact of specific chronic medical conditions and their combinations on survival. It will further allow estimations of lifetime prevalence of inpatient health care use due to specified multimorbid conditions and will enable to explore changes of pathways of inpatient care at the end-of-life before and after the implementation of the new Swiss reimbursement system (SwissDRG). We expect that this novel information will contribute to the international discussion on dying with dignity and to the political decision making and health policy development in Switzerland.