Perceptions of hospital-dependent patients on their needs for hospitalization
In the United States, older adults account for a significant proportion of hospitalizations, and a subset become hospital-dependent, for reasons that are unclear. We conducted a qualitative study to explore these individuals’ perspectives on their need for hospitalizations. Twenty patients hospitalized at an academic medical center underwent semistructured qualitative interviews. Criteria for selection included age 65 and older, at least three hospitalizations over six months, admission to the medical service at the time of the study, did not meet criteria for chronic critical illness, was not comfort measures only, and did not have a conservator. Interviews were audiotaped, transcribed, and inductively analyzed. The major themes derived were the necessity and inevitability of hospitalizations (“You have to bring me in here”), feeling safe in the hospital (“It makes me feel more secure”), patients hospitalized despite having outside medical and social support (“I have everything”), and inadequate goals-of-care discussions (“It just doesn’t occur to me”). Results suggested that candid discussions about health trajectories are needed to ensure hospitalization is consistent with the patient’s realistic health priorities. Journal of Hospital Medicine 2017;12:450-453. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
In the United States, patients 65 years old or older accounted for more than one third of inpatient stays and 42% of inpatient care spending in 2012.1 Despite the identification of risk factors, the implementation of an array of interventions, and the institution of penalties on hospitals, a subset of older adults continues to spend significant time in the hospital.2,3
Hospital dependency is a concept that was only recently described. It identifies patients who improve while in the hospital but quickly deteriorate after leaving the hospital, resulting in recurring hospitalizations.4 Although little is known about hospital-dependent patients, studies have explored patients’ perspectives on readmissions.5,6 Nevertheless, it remains unclear whether there are individuals for whom frequent and prolonged hospitalizations are appropriate, and whether there are undisclosed factors that, if addressed, could decrease their hospital dependency. We conducted an exploratory study to ascertain hospital-dependent patients’ perspectives on their needs for hospitalizations.
METHODS
Study Design
This study was approved by the Yale University Institutional Review Board. From March 2015 to September 2015, Dr. Liu conducted semistructured explorative interviews with patients on the medical units of an academic medical center. Dr. Liu was not directly involved in the care of these patients. An interview guide that includes open-ended questions was created to elicit patients’ perspectives on their need for hospitalizations, health status, and outside-hospital support. This guide was pilot-tested with 6 patients, whose transcripts were not included in the final analysis, to assess for ease of understanding. After the pilot interviews, the questions were revised, and the final guide consists of 12 questions (Supplemental Table).
Recruitment
We used predetermined criteria and a purposeful sampling strategy to select potential study participants. We identified participants by periodically (~once a week) reviewing the electronic medical records of all patients admitted to the medicine service during the study period. Eligible patients were 65 years old or older and had at least 3 hospitalizations over the preceding 6 months. Patients were excluded if they met our chronic critical illness criteria: mechanical ventilation for more than 21 days, history of tracheotomy for failed weaning from mechanical ventilation,7 presence of a conservator, or admission only for comfort measures. Participants were recruited until no new themes emerged.
Data Collection
Twenty-nine patients were eligible. We obtained permission from their inpatient providers to approach them about the study. Of the 29 patients, 26 agreed to be interviewed, and 3 declined. Of the 26 participants, 6 underwent pilot interviews, and 20 underwent formal interviews with use of the finalized interview guide. The interviews, conducted in the hospital while the participants were hospitalized, lasted 17 minutes on average. The interviews were transcribed and iteratively analyzed. The themes that emerged from the initial interviews were further explored and validated in subsequent interviews. Interviews were conducted until theoretical saturation was reached and no new themes were derived from them. Demographic information, including age, sex, ethnicity, and marital status, was also collected.
Analysis
Interviews were digitally recorded and transcribed. Independently, two investigators used Atlas Ti software to analyze and code the interview transcriptions. An inductive approach was used to identify new codes from the data.8 The coders then met to discuss repeating ideas based on the codes. When a code was identified by one coder but not the other, or when there was disagreement about interpretation of a code, the coders returned to the relevant text to reach consensus and to determine whether to include or discard the code.9 We then organized and reorganized repeating ideas based on their conceptual similarities to determine the themes and subthemes.9
