After classifying the 3,015 total BB cases found in the study period [19] by pathology, the cases of patients admitted with a diagnosis of stroke represented the largest group. The literature identifies stroke and nervous system diseases in general as a pathology of special risk for delayed discharge. This fact is related to the supervening disability that makes it difficult for the patient to return to the usual environment after hospitalization [7, 10, 11, 20, 21]. However, compared with the total number of stroke cases discharged during the study period, cases of stroke with BB accounted for a very small proportion of all cases. The literature on this subject shows considerable variations in prevalence depending on the context [12], in our case being the total number of discharges from all hospital departments over a nine-year period. Furthermore, in our context, the data on the duration of hospital stays suggest a possible problem of underdiagnosis.
In our study, the days of prolonged stay in stroke cases due to delayed discharge for non-clinical reasons accounted for a quarter of the total length of stay. However, considering the length of stay that would have corresponded to a similar case with the same DRG and year of discharge, the total length of stay practically doubled. Our results suggest a covert delayed discharge, since medical discharge does not depend on objective criteria based solely on clinical criteria, and therefore both the number of cases of delayed discharge for non-clinical reasons and their prolonged length of stay would most likely be greater. The UK National Health Service sets clear criteria for when a patient is considered ready to go home from an inpatient resource: a decision by the clinician that the patient is ready to go home (in acute inpatient settings), or a decision by the multidisciplinary care team (in the case of chronic inpatient settings) and whether such discharge is considered safe for the patient. These criteria depend on whether the patient requires inpatient care, but not whether the patient has regained his or her previous level of function [22]. For an accurate measure of length of stay in cases of delayed discharge, a true record of the date of discharge is important, specifying the clinical criteria [23].
In our study, 15.8% of the total cost of the stay of stroke cases depends on the cost of prolonged stay. This total cost is lower in the case of stroke cases compared to the total number of cases of delayed discharge for non-clinical reasons, however, this difference is not significant, as is the case with the complexity according to DRG weight. The mean DRG weight found was 2.98, which translates into a relatively high complexity based on a reference patient weight=1 [18]. Both variables are related, since the greater the weight of the DRG, the higher the cost, as a greater number and greater complexity of diagnostic and therapeutic procedures are required. The cost of hospital treatment of stroke cases depends fundamentally on the hospital stay and diagnostic procedures. Surgical procedures or intensive care are much less frequent and therefore have less influence on the cost of the process, and this may be the reason for the difference with other cases of delayed discharge [24]. In general, this complexity reflected in the weight of the DRG is related to longer lengths of stay [25], however, in our cases, we found a wide range between 0.81-4.79. Cases with complexity lower than 1, which would be apparently simple cases but with delayed discharge, could have been admitted for social problems, with similar results found in cases of hospitalization of homeless people [26].
In our study, we did not find differences in the proportion of men and women between patients with delayed discharge with and without stroke, nor was gender related to longer length of stay. A significant difference in age according to gender appears in those stroke patients affected by delayed discharge for non-clinical reasons, with women being older than men. This could be due to the pathology itself, since national studies show a higher incidence of stroke in men, which decreases with age in those over 85 years [3]. Moreover, although the role of gender in delayed discharge for non-clinical reasons is inconclusive [7, 25, 27], the occurrence of differential delayed discharge in two profiles of young men or older women may reflect different causes in each gender related to the lack of caregiver or social support, which are factors related to the problem [10, 28–30]. To explain the profile of women, when consulting other studies, we found a relationship between longer hospital stays when patients who previously lived alone were admitted, and it was more likely that these patients were women, of advanced age, with a good previous functional and cognitive level, and without a spouse or caregiver [31]. In addition, women may be more likely to be referred to a residential care facility for dependent persons [7]. Furthermore, to explain the profile of the men, we know that, in our environment, family caregivers are traditionally women, generally the wife or daughter, with a low level of education and working as housewives [32]. The profile of cases in younger men could be explained by a lack of caregiver or family support when the situation of loss of functional capacity related to the reason for admission is unexpected.
In our study, the mean age was 80.22 years, which was significantly higher in patients with stroke than in other patients. Numerous studies in the literature coincide in highlighting the greater probability of suffering BB at an older age [7, 20, 33, 34] specifically, the relationship between the lengthening of hospital stay in patients with non-traumatic brain injury and older age [35]. However, we found a wide age range, 45 and 103 years, and a longer total length of stay in younger patients affected by delayed discharge. We found other studies that relate younger age in delayed discharge with longer length of stay [25, 36, 37]. Younger patients may have greater difficulty being admitted to long-stay convalescent or rehabilitation facilities after discharge, and have more complex care needs, as pathologies involving loss of functional capacity are less likely to occur in young people and, because of their unexpectedness, these may be more difficult to assume by the family care network.
Regarding the context of care, most of our cases resided in the urban area coinciding with the district where the hospital is located. Other authors found longer stays in residents in the same area as the hospital [25], this could be explained by the use of the hospital itself as a temporary stay resource due to the lack of social and health services. However, in the same urban area as the study, there is a long-stay center for functional recovery, which was the most common discharge destination in cases of stroke with BB. The destination at discharge was not related to the length of stay in our cases, and the literature consulted provides sufficient evidence that in the case of stroke, the availability of long-stay recovery centers in the patients' area of residence does not determine their post-discharge referral, depending more on factors such as age or the complexity of the patient's condition [7]. Planning communication at discharge with the resource that will subsequently receive the patient, regardless of whether it is a residential center or the community, has proven to be an effective measure to promote continuity of care [38], avoid BB and reduce LOS [14]. Such communication should be standardized, possibly via the help of a liaison professional or by using technological means [14, 38]. In our cases, stroke patients who returned home after BB had a higher mean LOS, although this difference was not significant. To favor the preparation of patients and their families for discharge home, we recommend assessing factors such as self-care skills, functional level, caregiver support, presence of symptoms, adherence to prescriptions, the need to adapt the home to make it safer, or relationship with community resources to favor discharge [39].
Practically all the cases found of patients with stroke and BB were admitted urgently, which is to be expected, as a pathology of unpredictable onset. There were few cases of scheduled admissions, however, the total length of stay was significantly longer. On reviewing the characteristics of these cases, these are relatively young cases, with a mean age of 70.07 years, of heterogeneous etiology, both hemorrhagic and ischemic, and were patients who were admitted by the neurology service who did not require surgery. The hospital under study is a national reference hospital for certain services of high healthcare and technological qualification, with these cases being classified as programmed admissions, referrals from other hospitals in the same region of lesser complexity that cases requiring more complex studies or therapeutic procedures.
The highest number of cases were recorded in 2008, with a certain downward trend thereafter, although without significant differences with the total number of cases or evidence that the total length of stay decreases over the years. This result is consistent with the progression found by the authors in terms of the total sample [19] and with studies that demonstrate the effect of the implementation of the System of Care for Dependent Persons in Spain on hospital stay [40].
As strengths, studies on delayed discharge for nonclinical reasons in Spain are scarce and those found only focus on clinical [20] or socioeconomic [40] variables, without relating both fields as in the present study. The study spans a total of nine years, coinciding with the introduction of the dependency care system and the economic recession, and in all the units of a highly complex hospital in one of the most aged regions of the country [41].
Regarding the limitations of this study, the variables analyzed are based on data collected through the MBDS. This system collects variables at hospital discharge in a systematic, homogeneous, and objective manner. Demographic, clinical (DRG), type of care or social context data were collected, which could be related to delayed discharge for strictly non-clinical reasons. The use of these MBDS records, in addition to guaranteeing systematically collected data, enabled us to handle a large amount of data from a wide period. However, in the process of patient care, other variables that have been shown to be related to the problem, such as lack of social or family support, are collected in the patient's clinical history [10, 20, 28], previously residing alone [30] or increasing their level of dependence for self-care [7, 10, 11, 34]. These data are not objectively reflected in the MBDS, rather, this kind of data is lost and requires a dedicated review of the information recorded by the professionals in the patient’s clinical history.