Title Page
Title
The cost of hospital-acquired complications for older people with and without dementia; a
retrospective cohort study.
Author List
Assistant Professor Kasia Bail
Kasia.Bail@canberra.edu.au
University of Canberra, Faculty of Health,
College st. Bruce ACT 2601 Australia
Associate Professor John Goss
University of Canberra, Faculty of Health,
John.Goss@canberra.edu.au
University of Canberra
College st. Bruce ACT 2601 Australia
Professor Brian Draper
University of New South Wales, School of Psychiatry and Prince of Wales Hospital,
Department of Old Age Psychiatry
B.Draper@unsw.edu.au
Euroa Centre, Prince of Wales Hospital, Randwick NSW 2031 Australia
Professor Helen Berry
Helen.Berry@canberra.edu.au
University of Canberra, Centre for Research and Action in Public Health
College st. Bruce ACT 2601 Australia
Ms Rosemary Karmel
karmelro@aihw.gov.au
Australian Institute of Health and Welfare, Data Linkage Unit
1 Thynne Street, Fern Hill Park, Bruce ACT 2617, Australia
Professor Diane Gibson
Diane.Gibson@canberra.edu.au
University of Canberra, Faculty of Health
College st. Bruce ACT 2601 Australia
Corresponding Author
Kasia Bail
Assistant Professor, Faculty of Health, University of Canberra
Address: Room 22B30, College st, Bruce, ACT 2601
T: +61(0)2 6201 2851
E: Kasia.Bail@canberra.edu.au
Abstract
Background: Increased length of stay and high rates of adverse clinical events in hospitalised
patients with dementia is stimulating interest and debate about what costs may be associated, and
potentially avoided, with this population.
Methods: A retrospective cohort study was designed to identify and compare costs for older people in
relation to hospital-acquired complications and dementia. Australia’s most populous state provided a
census sample of 426,276 discharged overnight public hospital episodes for patients aged 50+ in the
2006-07 financial year. Four common hospital-acquired complications (urinary tract infections,
pressure areas, pneumonia, and delirium) were risk-adjusted at the episode level. Extra costs were
attributed to patient length of stay above the average for each patient’s Diagnosis Related Group, with
separate identification of fixed and variable costs (all in Australian dollars).
Results: These four complications were found to be associated with 24.7% of the extra cost of aboveaverage length of stay spent in hospital for older patients, costing the state A$226 million in a single
financial year. Dementia patients were more likely than non-dementia patients to have complications
(RR 2.5, p <0.001) and comprised 22.0% of the extra costs (A$49 million), despite only accounting
for 10.4% of the hospital episodes. The complications were found to be associated with an increased
length of stay of 3.6 days and a mean episode cost of A$16,403 for patients with and without
dementia.
Conclusion: These four complications demonstrate a burdensome financial cost and are revealed as
key in understanding increased length of stay and costs in older and complex patients. Once a
complication occurs, the cost is similar for people with and without dementia, however they occur
more often among dementia patients. Research on models of care, nurse skill-mix and healthy work
environments show promise in prevention of these complications for both dementia and non-dementia
patients.
Acknowledgements
The Hospital Dementia Services Project was funded by the National Health and Medical
Research Council (ID465701). Dementia Collaborative Research Centres provided a PhD
scholarship to the first author.
Competing Interests
All authors have completed an ICMJE Form for Disclosure of Potential Conflicts of Interest.
We acknowledge: grant funding from Dementia Collaborative Research Centres (DCRC) and
National Health and Medical Research Council paid to authors’ institutions; and travel
support for meetings paid by DCRC to authors’ institutions. Other disclosable relationships
are: participation in a team and consultancy paid by Alzheimer’s Australia which uses some
of the same database for some of the analysis; a NSW Government funded project related to
the Hospital Dementia Study held by Alzheimer’s Australia NSW focusing on the experience
of people with dementia discharged home from hospital relating to availability and suitability
of community-based services; Pfizer paid travel expenses to present data from the Hospital
Dementia Services study at education meeting they sponsored (but refused speaker’s fee);
Department of Health and Ageing Australia paid travel expenses to present data from the
Hospital Dementia Services study at an educational meeting they sponsored. We have no
other financial or non-financial competing interests to disclose.
Author’s contribution
KB conceived, designed and performed the ‘nurse-sensitive hospital-acquired complications’
study nested in the Hospital Dementia Services project. DG, BD and RK conceived, designed
and performed the Hospital Dementia Services project. KB, JG, HB and RK made substantial
contributions in the analysis and interpretation of the ‘complications’ data. All authors have
been involved in drafting the manuscript or revising it critically for important intellectual
content and have read and approved the final manuscript.
STROBE checklist
Availability of Supporting Data section
MS: 1748809060143739
To submit your revised manuscript
When you have revised your manuscript having taken the requested comments into consideration
and made any required changes to the format of your paper, please upload the revised version by
following these instructions:
1. Go to
http://www.biomedcentral.com/manuscript/login/man.asp?txt_nav=man&txt_man_id=1748809060
143739 and log on with your email address and password.
2. With the 'Manuscript details' tab, please update the title, abstract and author details if they have
changed since the previous version. It is very important that all changes are updated on this page, as
well as in the manuscript file as the information on this page will be used in PubMed and on BioMed
Central if your manuscript is accepted for publication.
3. With the 'Cover letter' tab, please provide a covering letter with a point-by-point description of
the changes made.
4. With the 'Upload files' tab, please upload the revised version of the manuscript and press 'Submit
new version'.
Please wait for the confirmation page to appear - this may take a few moments. We would be
grateful if you could resubmit your files with the changes requested within the next week.
Please note that all submissions to BMC Health Services Research must comply with our editorial
policies. In particular, please ensure that your manuscript contains any required statements
regarding ethical approval and consent from patients/ participants; adheres to any relevant
standards of reporting with a completed checklist where appropriate; and contains an Availability of
Supporting Data section explaining how the supporting data is available to researchers, including the
repository and accession number where appropriate. Manuscripts which do not adhere to our
editorial policies may experience delays or be rejected. Further information about our editorial
policies can be found at the following links:
Ethical approval and consent: http://www.biomedcentral.com/about/editorialpolicies#Ethics
Standards of reporting:
http://www.biomedcentral.com/about/editorialpolicies#StandardsofReporting
Data availability: http://www.biomedcentral.com/about/editorialpolicies#DataandMaterialRelease.
Please do not hesitate to contact us if you have any questions.
Best wishes,
Armee
Armee Valencia
Journal Editorial Office
Biomed Central
E: editorial@biomedcentral.com
W: www.biomedcentral.com