Factors associated with inadequate Hospitalizations of older adults in the Emergency Department of the Hospital Edgardo Rebagliati Martins 2017

Introduction:Inadequate hospitalizations (IH) alter hospital management and much more when they are carried out in the elderly population; therefore, identifying the factors is relevant at the national and local levels. Objective: To determine the factors associated with IH in older adults in the Emergency Service (ES) of the Edgardo Rebagliati Martins National Hospital (HNERM) during 2017. Methods: Observational, analytical, cross-sectional study. A sample of 414 patients randomly selected from 18 250 patients admitted during the study period was selected. Collection forms were used, and medical records were reviewed. With the help of the SPSS 25 program, the Chi-square test was performed, and the simple Prevalence Ratio (PR) and adjusted (Rpa) were calculated. The level of signicance was 5%. Results: The frequency of IH was 11,8%. The epidemiological factors associated with IH were ages from 75 to 84 years RPa=5,80 (2,20-15,27) and from 85 to more years RPa=8,22 (2,76-24,44), the female sex RPa=2,20 (1,11-3,10), the occupation as a housewife RPa=3,39 (1,13-10,17) and the accompaniment of the spouse RPa= 9,16 (2,59-32,38), child RPa= 3,72 (1,14-12,14), parents RPa= 8,50 (1,88-38,44) and siblings RPa=22,42 (5,78-86,97). The organizational factors associated with IH were internist treating physician RPa=2,90 (1,38-6,07) and admisiion morning shift RPa=4,84 (1,67-14,06). Conclusions: There are factors associated with IH in older adults in the SE of HNERM.


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All countries worldwide have experienced growth in (1) the proportion of people 60 years and over in the (2) population, being called the older adult population .
According to statistics provided by the World Health Organization (WHO), in 2019, more than a billion people were 60 years of age or older, while by 2030, it is expected that one in six people in the world will be in this age range. In the year 2050, the proportion of this population group would be 22%, doubling the ratio (3) identi ed in 2015 (12%) .
This new population distribution, known as population aging, began in high-income countries, such as Japan, (4) Korea, France, Sweden, and the United Kingdom . Still, later, speci cally by 2050, two-thirds of this population will be concentrated in low-and middle-income (3) countries .
The signi cant change in the world population causes each country to carry out a diversity of adaptations (1) structured in the various social sectors prioritizing health care because it is a basic need for every person.
Therefore, a large part of health spending is provided to (5) hospital services, with making them effective during and for care. The rational use of beds and adequate hospital stay are valuable indicators of quality and (6) management .
Under these indicators, it has been possible to identify that in some cases, health care may be unnecessary through the evaluation of inadequate hospitalizations (7) (IH) since these increase hospital costs, reduce the resources available for patients in critical situations, generate poor health services, increase the mortality rate and put the patient at risk of suffering from (8) nosocomial infections, thereby altering .
Inappropriate hospitalizations are diverse worldwide , (9) varying between 9% and 23% , while in China, this frequency is 5,6%, speci cally in patients 65 years of (7) age or older . In the case of Europe, the rate of inappropriate hospitalization varies from 6% to 78% in (8) elderly patients , while in Latin America, unjusti ed (10) hospital admissions run between 6% to 54% . And in the case of the national environment, the frequency of (11,12) IH ranges from 1,8% to 11,7% .

Design and study area
This study is observational, analytical, and crosssectional carried out from the clinical records of the HNERM, administered by the Social Security of Health (EsSalud) and categorized in the third level of care 2, located in the district of Jesús María, department of Lima, Perú.

METHODS
Because in Peru, the process of population aging has also been identi ed through the report provided by the "National Institute of Statistics and Informatics (INEI)" where the proportion of the older adult population increased by 13% in 2021, compared to 1950, which was 5,7%, and that in the last three months of 2021, 39% of Peruvian households had at least one person over 60 years of age among their members, Being in Metropolitan Lima the province with the highest (14) proportion (41,8%) , it is that this study is carried out under the institutional reality of the HNER M, speci cally in the SE of adults. For this reason, this study aims to determine the factors associated with IH of older adults in the emergency service of the Hospital Edgardo Rebagliati Martins, 2017.
In these hospitalizations, it has been possible to identify studies, mainly in the international environment, that have placed their associated factors, such as for (13) example, sex, insurance coverage , service for which (12) the patient was admitted, care shift , admission diagnosis, time of illness, among others. Still, these factors are linked to IH in the hospital setting but are not speci c to the emergency service, as is done in this study.

Population and sample
The study population consisted of 18,250 elderly patients hospitalized in the SE of the HNERM from January to December 2017 (sample frame). To calculate the sample size, the formula was applied to estimate a (15) proportion when the size of the population is known; Given that the prevalence of IH in HNERM emergencies was unknown, a proportion of 50% (p=0,50) was assumed, in addition, a con dence level of 95%  inter-rater agreement of hospital admissions presented a kappa coefficient >0.70; then, when calculating the speci city and negative predictive value to detect adequate admission, the values found were >94% and >98%, respectively. In addition, this instrument has been applied in a variety of studies in the national environment, such as example, the one prepared by (19) Contreras and Galarza at the Dos de Mayo National (11) Hospital, and the one carried out by Valentín at the Daniel Teaching Hospital Alcides Carrion of Huancayo.

Procedures
The collection technique was documentary research, that is, data collection from secondary sources; in this case, the review of HC was carried out, the H: C were

RESULTS
In the present investigation, 414 patients hospitalized in the SEHNERM during 2017 were included. The frequency of IH was 11,8% (n=49), while that of adequate hospitalizations was 88,2% (n= 365).
The descriptive analysis of the qualitative variables was carried out using absolute frequencies (n) and percentages (%). The bivariate analysis was performed using the Chi-square test, a level of statistical signi cance of 5%. Regression analysis was performed to determine the factors associated with IH, the simple Prevalence Ratio (PR) and adjusted (PRa) were calculated, with their respective 95% con dence interval.
The institutional permits of the nosocomial entity were obtained for the development and execution of this research, and the approval of the Institutional Ethics Committee and the con dentiality of the HC patients were maintained. Physical selected by encoding the data used.       When identifying the associated factors, it was found t h a t a g e w a s a n e p i d e m i o l o g i c a l f a c t o r fo r inappropriate hospitalizations because the older the patient, the greater the possibility of being hospitalized inappropriately. Almost similar results were identi ed (22) in the study performed by Li et al. who While the occupation of housewife was another epidemiological factor found; where Contreras and (19) Galarza contrast with what was mentioned since they showed that patients who were students and/or employees were the ones who had a double risk of being hospitalized unnecessarily ( p=0.01, OR=2.35).
The disparity in results could be based on the fact that those patients who have a de nite occupation are more likely to have some type of occupational accident, causing them to be the ones who require more health care and, given the need to receive a de nitive diagnosis, their hospitalization results be prolonged and inadequate in the face of waiting for results.
Given these results, it could be mentioned that, when the patient is accompanied by a family member, in general, they ask for the best care for their patient, thus generating a prolonged and unnecessary stay until they obtain a response from the specialists on the health of this But it can also be mentioned that, if the patient goes to a health institution on their own, this can generate u n n e c e s s a r y h o s p i t a l i z a t i o n , b e c a u s e t h e administrative process, obtaining medications, among other aspects necessary for patient care are detained until the arrival of a family member, triggering what was described above.
Likewise, the presence of a person accompanying the patient to the hospital, speci cally parents, siblings, and spouses, turned out to be another epidemiological factor, completely contrasting with what identi ed by (23) Hwang et al. since they found that the admission method, speci cally when the patient goes to the hospital alone, was associated with more days of inadequate hospitalization (p =0.05).
Additionally, it was found that the female sex was also an epidemiological fac tor for inappropr iate hospitalizations, which has not been identi ed as a factor associated with these hospitalizations in other related investigations but has been found in a way that describes that female patients are the ones who mainly (11) present this type of hospitalization .
On the other hand, the organizational factors identi ed were the treating physician, speci cally the internist.
It is concluded that the frequency of IH was 11.8% in the SE-HNERM. Service Emergency of the Edgardo Rebagliati Martins Hospital There were factors associated with inadequate IH hospitalizations: epidemiological (female sex, age, occupation as a housewife, accompanying parents and accompanying siblings) and organizational factors (internist treating physician and the morning admission shif t). Additionally, the afternoon and evening admission shifts were found as organizational factors.
The similarities of the results mentioned show that the specialist doctor's attention, judgment, and expertise are relevant to giving the hospitalization order and avoiding inappropriate hospitalizations.
It is recommended to plan and execute strategies aimed at medical personnel, speci cally those who work in the SE of the study hospital, to update their knowledge about hospitalization criteria, with the frequency of reducing the frequency of HI in ( 2 4 ) R e g a rd i n g t h i s, Co n t re ra s fo u n d t h a t t h e inappropriate hospitalizations occurred mainly when t h e y c a m e f r o m g e n e r a l m e d i c i n e ( 9 2 % ) , gastroenterology (71.43%), and hematology (62.50%) (p=0.001). In contrast, the admissions produced by outpatient clinics of other specialties than medicine had twice the probability of inappropriate admission (p=0.04 OR=2.10) and when hospitalization is generated by the general practitioner (p=0.001). In (21) agreement with what was identi ed by Borda , who showed that the inadequate hospitalizations were mainly when the origin of admission was from an outpatient clinic (p=<0.001), and the results of Sarzo et (25) al. , add that the admission diagnosis is a factor that was associated with inappropriate hospitalization (p=0.003).
Another organizational factor found was the admission (12) shift, speci cally the morning, as evidenced Chirinos where the admission shift was also a factor for inadequate hospital admission, but specifying that it was the afternoon shift, disagreeing with what was identi ed in this investigation. This could be due to the difference in the population analyzed in both studies, since in the present study, they were older adults. In contrast, in the study above, it was pediatric patients.

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In addition to greater awareness of specialists about the importance and need of the patient to be hospitalized or not, since this generates a reduction in the availability of hospital beds, causing patients who really need them to not be able to occupy them. And encourage the development of research related to the s u b j e c t o f s t u d y, c o n t e m p l a t i n g n o t o n l y hospitalization in the SE of the study institution, but of the entire nosocomial institution, as well as the identi cation of other factors that may be associated with IH in other nosocomial realities. this service.
Finally, the main limitation of this study is that the results obtained will be useful only for the hospital environment under study, demonstrating the reality found in a speci c year, for which they cannot be ex trapolated to other nosocomial instances. Subsequently, the variables analyzed in this study were of interest to the researcher, which is why he limited the comparison of the results, considering that, in several of them, these variables were not analyzed, but this can also be considered as an opportunity to the expansion of scienti c evidence both in the international environment and even more so in the national one, considering the little evidence found in this regard.