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The objective of this study was to assess complexity of patients discharged from hospital to intermediate care facility in an Italian setting. Multiple anonymous health-related databases were linked at the individual patient level through a stochastic key to study patients discharged from the University Hospital of Udine, Italy, from 2010 to 2019. Patient complexity was measured through diagnosis related group (DRG) relative weight of each hospitalization, number of chronic conditions and annual use of health resources. 12,674 intermediate care facility admissions were recorded in the study period. Mean DRG weight was 1.54±1.05 with variations depending on the discharging hospital ward. Patients discharged to intermediate facilities had higher DRG weight, had more comorbidities and consumed more health resources than the others, particularly in case of patients discharged from surgical wards. Patients discharged to intermediate care facilities are particularly complex, have high use of health resources, and may be difficult to manage. Introduction In Italy, intermediate care facilities (Residenze Sanitarie Assistenziali) were formally established with financial law 67 of 1988, as non-hospital residential healthcare facilities for the elderly and non-self sufficient persons who required continuous care but could not receive it at outpatient clinics or at home. The profile and role of intermediate care facilities have changed in time1 and today they are intermediate facilities between hospital and territory. To ensure the continuity of care to patients discharged from hospitals, procedures aiming at organizing the transition of patients to facilities offering lower intensity of care can be applied. Access to intermediate care facilities occurs after a multidimensional assessment of the patient. In the Italian Region Friuli Venezia Giulia (FVG), intermediate care facilities are managed by the local Ac ce pt ed p ap er health districts; they are rehabilitation-oriented residential facilities, providing continuous care (with high content of healthcare) to patients who are temporarily or permanently disabled and who can be classified, according to regional law DGR 1487 of 2000, into three types: i) with physical problems needing continuity of care; ii) with social or social and health problems; iii) with global problems needing high-intensity healthcare outside of the hospital. They are free of charge for the first 30 days for the basic care level and 40 days for rehabilitation.2 The local health agency Azienda Sanitaria Universitaria di Udine (ASUIUD) in the FVG Region includes three health districts serving an overall population of approximately 250,000 inhabitants in 37 municipalities, one 1000-bed academic hospital, and 5 intermediate care facilities (one is a hospice dedicated to the terminally ill). The inhabitants of those 37 municipalities, however, may be also admitted to other intermediate care facilities of the Region. In FVG, no clinical information or indicators of complexity of patients are recorded in the intermediate care facility electronic administrative databases: patients are only categorized according to generic types of problem (e.g., orthopaedic, heart, palliative care, dementia, compensated diabetes, diabetic with renal failure, alcohol abuse, chronic obstructive pulmonary disease (COPD), psychiatric, etc.) and demographic data. Thus, it is impossible to assess the level of complexity of patients only looking at data regarding the intermediate care facility episode of care. Nonetheless, information on complexity would be useful for improving the organization of services, which should take into account not only the number of patients but also their care needs. Limited data exist in Italy on the characterization of patients admitted to intermediate care facilities.3,4 Thus, we decided to conduct this study to quantify the level of complexity of patients discharged to intermediate care facilities from the Hospital of Udine, to assess whether such level of complexity has changed over time, and whether the average complexity of patients discharged to intermediate care faAc ce pt ed p ap er cilities is different from that of all patients discharged from the Hospital. Materials and Methods The source of information used in this study included various administrative health databases of ASUIUD: we analyzed the intermediate care facility database, the hospital discharge database, and the database of all residents in the municipalities served by the health districts of ASUIUD. These databases are made available for epidemiological analyses as completely anonymous data within a Regional Epidemiological Repository and can be linked which each other at the individual patient level through an anonymous stochastic key which is univocal for each subject in all databases. We used data from January 1st, 2010 to June 30th, 2019 (the most recent date with complete information at the time of analysis). The analyses regarded only patients living in the 37 municipalities of ASUIUD. To assess the level of complexity of nursing home patients, we linked to each intermediate care facility admission the hospital discharge, if any, which occurred on the same date or on the day before. Admissions to intermediate care facilities with no previous hospital discharge were considered as having a relief function and excluded from further analyses. We also excluded patients discharged from hospitals other than the Hospital of Udine. We attached the diagnosis related group (DRG) relative weight calculated in the hospitalization to all patients who were discharged from the Hospital of Udine. The DRG relative weight, which represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs, can be considered a proxy indicator of the complexity of the hospitalization, assuming that increased clinical complexity leads to increased resource use.5 We calculated the mean DRG weight for intermediate care facility patients, also stratified by calendar year and discipline of the discharging hospital ward according to the classification by the Italian MinAc ce pt ed p ap er istry of Health.6 We compared the average DRG weights of patients discharged to intermediate care facilities with the average among all patients discharged from the hospital wards in the same disciplines. We also assessed whether there was a correlation between DRG weight and intermediate care facility length of stay, to understand whether the complexity of the previous high-intensity-of-care hospitalization affected the length of stay in a facility with lower intensity of care. Then, only for year 2018, as additional estimates of patient complexity, we classified intermediate care facility patients according to: i) number of chronic conditions (from a list of 14: patient with transplanted organ, psychiatric disease, rare disease, disease of lipid metabolism, endocrine disease, autoimmune disease, neurologic disease, gastroenteric disease, COPD, cardiovascular disease, diabetes mellitus, cancer, HIV, chronic renal failure), according to algorithms by the Italian Local Health Unit of Brescia; 7 and ii) resource utilization bands (RUBs) obtained from the aggregation of adjusted clinical groups (ACG, which identify health problems with similar care impact) with the same expected consumption of resources (not only economic) through the Johns Hopkins ACG® System (Johns Hopkins ACG® v. 2.11.1). According to this system, the population under study can be divided into 6 possible levels: 0 – no diagnosis, no resource use; 1 – healthy user; 2 – low resource use; 3 – moderate resource use; 4 – high resource use; 5 – very high resource use. Data management and statistical analyses were conducted using SAS v 9.4 (SAS Institute Inc., Cary, NC, USA). Ac ce pt ed p ap er Ethical considerations All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Declaration of Helsinki. All the analyses were based on anonymous administrative data, therefore patient informed consent and Ethical Committee approval were not required in Italy. Results Between January 1st, 2010 and June 30th, 2019, 18,244 admissions to intermediate care facilities were recorded among the population of the 37 municipalities of ASUIUD; of them, 72% were healthcare oriented (not for giving relief to families). The overall number of admissions to intermediate care facilities increased steadily in the study period, from approximately 1700 in 2010 to >2000 per year after 2015. On the other hand, the proportion of admissions for healthcare purposes did not show a clear trend. In the 12,674 admissions to intermediate care facilities with healthcare purposes, mean age of patients was 79.5±10.5 years (median 81; 5° percentile 59; minimum 18), with virtually no changes in time (data not shown). Overall, 60.5% of patients were females. The proportion of females decreased progressively from 63% in 2010-2011 to 57% in 2018-2019. Mean DRG weight of the hospitalizations preceding the 12,674 admissions to intermediate care facilities was 1.54±1.05. Table 1 shows admissions to intermediate care facilities stratified by discipline of the discharging hospital ward (only for disciplines with >5 discharges to intermediate care facilities in the study period), and the overall hospital discharges from the same disciplines, with mean DRG weights and length of hospital stay. Overall, among patients hospitalized at the Hospital of Udine, mean weight was higher among patients who died in the hospital (1.49±1.34) than among the others (1.07±0.99). Disciplines discharging the highest numbers of patients to intermediate care facilities were general Ac ce pt ed p ap er medicine (>4000 discharges overall), orthopedics (almost 3000) and long-term care (>1000), follo

Who is discharged to intermediate care facilities? An Italian study in the population of Udine