A Retrospective Chart Review of the Prevalence, Characteristics, and Discharge Destinations of Patients Hospitalized as “Social Admissions”

Overview of study. The health of populations is shaped by the social determinants of health [1]. In circumstances where the social and medical supports are ineffective or absent, people can be admitted to hospital for purportedly purely social reasons [2]. When patients are considered “only a social admission,” the label can be stigmatizing [3]; hospital services may be less likely to do a full assessment resulting in the multifactorial medical and social factors pertaining to their presentation being overlooked [4]. Editorials suggest patients admitted for social reasons are common internationally and suffer poor health outcomes [2, 5, 6]. We examined the prevalence, characteristics, and discharge destinations through a retrospective chart review of patients admitted as “social admissions” at the QEII Health Sciences Center, a tertiary care center, in Nova Scotia, Canada, from January 1, 2011, to December 31, 2021. Definitions and nondiagnostic synonyms of “social admission” differ widely across regions. In Nova Scotia, the standardized policy is through the Orphan Patient Policy Pathway. They are seen by a physician in the Emergency Department (ED) to exclude acute or new medical conditions and a social worker or discharge planning nurse to exhaust options for home care. Patients are admitted and assigned to a bed and a responsible service (e.g., medical or surgical) on a rotating roster. Medical teams do not provide daily review, but address new medical issues that arise. Daily care is conducted by the multidisciplinary team (i.e., nurses), and rehabilitation (e.g., physiotherapy) involvement is often minimal if long-term care home (LTCH) placement is planned. Two sources were used: a “social admission” database collected by the hospital bed managers and patients' electronic hospital charts. Descriptive analyses were done using R Studio for Chi-square (with continuity correction), one-way ANOVA, and Wilcoxon (for skewed length of stay [LOS] data) tests of independence. Analyses were stratified by sex and age (< 70 and 70+, except for prevalence estimates). The study was approved by the Nova Scotia Health Research Ethics Board (No. 1027628). Three hundred and fifty-nine “social admission” hospitalizations accounted for 20,671 total days in hospital and 729 days in the ED. Eight patients had two to five distinct admissions under this policy for a collective LOS of 763 days. From 2011 to 2016, counts ranged from 3 to 18 per year. Due to the availability of ED data, prevalence compared to all hospital admissions was calculated for 2017 to 2021 only at 0.064%, 0.056%, 0.076%, 0.24%, and 0.26% of ED visits per year (counts of 25, 23, 31, 92, and 105, respectively). Among older adults aged 65 years and older, the annual prevalence was 0.10%, 0.085%, 0.12%, 0.36%, and 0.37%. To summarize medical and social characteristics by person (Table 1), we used their first admission (n = 348). Males tended to be younger, married, had more heart disease and stroke, and significantly more alcohol use disorder (e.g., one in four). Approximately half the cohort lived alone prior to admission. Ages ranged from 28 to 101 years old. People below the age of 70 years had more alcohol use disorder and intellectual disabilities. Older adults were more likely to be confused, with 70.2% having a dementia diagnosis. Geriatric medicine was consulted the most (31.3%). Individual LOS ranged from 2 to 893 days, with a mean of 58.3 (SD 96.7) and a median of 25 (IQR 55.25). Women had shorter LOS than men. Older adults had shorter LOS than younger patients. One in eight patients died in hospital, and 66.8% of older adults were discharged to an LTCH (Table 2). We note this pathway was often used for older adults with cognitive impairment. This could suggest that dementia is framed as a social problem rather than a medical condition. Second, we identified a younger subgroup with distinct social vulnerabilities, who had prolonged hospital stays, perhaps because of uncertainty about appropriate care pathways. Third, high mortality rates and prolonged LOS could point to gaps in both early and ongoing medical assessment. Missed sepsis, malignancies, delirium, and other acute medical issues have been documented in this population, leading to avoidable harm [7-9]. This may reflect missed opportunities for intervention, such as comprehensive geriatric assessments, to avoid unnecessary LTCH placements and improve the quality of end-of-life care [10]. While not generalizable to other sites, the increasing number of patients with complex medical and social needs that do not fit within acute hospital care models led to the use of “social admission” labeling as a triage strategy in Nova Scotia, resulting in disproportionately long stays for just 348 patients and challenging the assumption that “social admissions” are purely social problems. J.M. contributed to the conceptualization and design, procurement of data, analysis of data, drafting of the original manuscript, and review of the manuscript. L.E., L.P., C.S., K.N., H.F., C.L., K.K., V.H., M.M.-G.S, and L.L. contributed to the conceptualization and design, procurement of data, analysis of data, and review of the manuscript. G.L., K.K., S.F., M.v.M., K.R., S.D.S., and M.K.A. contributed to the conceptualization and design, analysis of data, drafting of the original manuscript, or review of manuscript drafts. The authors have nothing to report. M.K.A. reports grants from Sanofi, grants from GSK, grants from Pfizer, grants from the Canadian Frailty Network, personal fees from Sanofi, personal fees from Pfizer, personal fees from Seqirus, grants from Merck, grants from the Public Health Agency of Canada, and grants from the Canadian Institutes of Health Research, outside the submitted work. She is the current Kathryn Allen Weldon Chair in Alzheimer's Research. K.R. has asserted copyright of the Clinical Frailty Scale through Dalhousie University's Industry, Liaison, and Innovation Office. Use is free for education, research, and not-for-profit health care. Users agree not to change or commercialize the scale. In addition to academic and hospital appointments, K.R. is co-founder of Ardea Outcomes, which (as DGI Clinical) in the last three years has had contracts with pharma and device manufacturers (Danone, Hollister, INmune, Novartis, and Takeda) on individualized outcome measurement. In 2020, he attended an advisory board meeting with Nutricia on dementia and chaired a Scientific Workshop & Technical Review Panel on frailty for the Singapore National Research Foundation. He is Associate Director of the Canadian Consortium on Neurodegeneration in Aging, which is funded by the Canadian Institutes for Health Research, the Alzheimer Society of Canada, and several other charities. He held the Kathryn Allen Weldon Chair in Alzheimer Research, funded by the Dalhousie Medical Research Foundation. The remaining authors have no other conflicts of interest or additional sources of funding to declare. K.R., M.K.A., and J.M. are part of the Canadian Consortium on Neurodegeneration in Aging (CCNA) Team 14, which investigates how multi-morbidity, frailty, and social context modify the risk of dementia and patterns of disease expression. The CCNA receives funding from the Canadian Institutes of Health Research (CNA-137794) and partner organizations (www.ccna-ccnv.ca).