The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M190-M191 (2003)
© 2003 The Gerontological Society of America
THE NETWORK FOR ELDERLY CARE IN ITALY: ONLY A CORRECT USE OF ACUTE WARDS ALLOWS AN OVERALL FUNCTIONING OF THE HEALTH CARE SYSTEM
Renzo Rozzini,
Tony Sabatini and
Marco Trabucchi
Poliambulanza Hospital and Geriatric Research Group via Romanino 1 25122 Brescia (Italy) E-mail: renzo.rozzini{at}iol.it
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To the Editor:
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Recently the debate on the benefits of geriatric care has been reopened. Major statements indicate that they are not as dramatic as hypothesized in the early days of the geriatric discipline (1–4); on this level, some authors suggest that it is possible to manage acutely ill elderly patients in the community (5). These questions produce some worries, since a downgrading of acute geriatric care could hamper the entire network of elderly care, preventing a correct allocation of patients on the basis of their clinical needs.
We would like to offer some ideas concerning these problems on the basis of our experience in Italy and, in particular, that of the region of Lombardy (nine million inhabitants). Due to the recent reform of the National Health Service, Italy adopted a semifederal organization of health services, leaving to the 19 regions of our country the responsibility to independently structure the various levels of the health care network. Lombardy decided to have 4 acute hospital beds/1000 and 1.5 rehabilitative beds/1000, with a program to reduce in 10 years the burden of costs due to hospitals from the actual 47% to approximately 40% of the total health budget.
In this framework, the problem of elderly hospitalization is becoming of great importance, since the new rules tend to dramatically reduce both the number of admissions and the length of stay.
Nevertheless, no serious alternatives to hospital admission have so far been proposed in our region (6,7). "Low tech" facilities are too often equivalent to "no tech" ones, and the risk of adopting solutions inadequate for elderly sick people is very high (4). However it is not feasible to request more beds for acute elderly patients without being able to indicate the real needs concerning their numbers and characteristics. We are still confusing the social needs of a better home care delivery system to avoid institutionalization with what is important for an increasing number of citizens with complex problems not affordable in an environment with a reduced level of medical intensity.
Paradoxically, we must admit that geriatrics in Italy in the more recent years gave scanty attention to the acute care of elderly people by concentrating its interests mainly on long-term care with special attention to nursing homes. In this framework, the pressure of increasing costs forced politicians and health managers to reduce the number of hospital beds as the only way to control expenditures, erroneously maintaining that increasing appropriateness of admissions would concentrate the financial efforts on the patients really needing hospitals, and almost automatically on those following other pathways of care. We think that the only way to fight this tendency is to better define the clinical profile of sick elderly persons, the procedures to adopt, and the expected outcomes for the different services, counteracting the conviction that reducing hospital beds allows the transfer of new economical resources to the long-care system.
As recently discussed by Avorn (5), in the field of medication use, the problem is not only reducing hospitalizations, but avoiding "a perverse mix of overtreatment and undertreatment," i.e., finding the correct balance of care given by hospitals and outside sources, "desperately" avoiding the risk of undertreatment. In this light, it is also dangerous to look at the problems in this perspective by finding novel uses for hospitals that are closing or downsizing (8), since the correct care of the elderly requires fully operating hospitals (with all the technological equipment devoted to the care of adults). To support this statement, in Table 1 we reported data on 3000 patients consecutively admitted to our 24-bed Medical Unit for the Acute Care of the Elderly (Poliambulanza Hospital, Brescia, Italy) in the last 3 years (since the opening of the ward) (8,9). The patients were very old, mainly women, disabled, and affected by a high level of comorbidity. We stress that, although they had a relatively short length of stay, patients underwent a large number of advanced procedures not feasible in "low or no tech" facilities. We would also like to stress that 12% of the patients were admitted from nursing homes, 13% were being supported by a home care system, and 16% were living with a paid caregiver. For all of these elderly persons, the only intensive medical support may be provided by hospital care. In our system, a further reduction of hospital bed utilization would impair the overall quality of care. On the other hand, if clinical needs were those of subacute (postacute) care, there are dedicated facilities, although the debate on their role is still confusing; moreover, subacute wards may not exert their role if overwhelmed by patients with critical problems.
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Table 1. Characteristics of 3000 Elderly Patients Consecutively Admitted to a Medical Unit for the Acute Care of the Elderly
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The point is to avoid misplacement only because of age: We need "new ideas" in this field and not a "new ageism" induced by the social and economical burden of an increasing number of older citizens. In particular, an equitable network system may work only if all segments have a specific mission without the burden of inappropriately placed patients.
Received July 30, 2002
Accepted August 2, 2002
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- Rozzini R, Trabucchi M. Improving communication between researchers and policy makers in long term care: or researchers are from Mars; policy makers are from Venus (response letter). Gerontologist. 2001; 41:830-831.
- Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332:1338-1344.[Abstract/Free Full Text]
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