Quality and safety of acute hospital care for older patients
Authors:   , Schouten Bo 
Published: January 2024

The World Health Organization defines quality of care as: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes, based on evidence-based professional knowledge”. There has been widespread international attention for quality of care. Despite the importance and efforts already made, ensuring high standards of care delivery can be challenging for healthcare professionals and –organizations. This thesis aims to contribute to the understanding of quality of acute hospital care for older patients, focused on patient safety, patient-centeredness and timeliness of care. We aimed to answer the following research questions:
I.	How safe is acute hospital care for older patients over time and currently?
II.	How patient-centered is acute hospital care for older patients?
III.	How timely is acute hospital care for older patients?

In part I of this thesis multiple studies are described on the topic of patient safety. Chapter 2 shows that the incidence of AEs in older acutely admitted patients declined over the years (2008-2016). However, the preventability increased again after an initial decline. In chapter 3 we found a high prevalence of (fatal) AEs in older patients undergoing total hip arthroplasty or hemi-arthroplasty for a femoral neck fracture. This seemed particularly valid for cemented implants in highly frail old patients. In chapter 4 we found that AE risks appeared to be equally prevalent in patients with- and patients without a condition relevant for palliative care. But, the nature of AEs did differ between groups: medication- versus surgery-related. Based on the results of these studies, our answer to research question 1 is that although improvements have been made over the years, there is still room for improvement in patient safety for older patients.

In part II we described multiple studies on the topic of patient-centeredness. In chapter 5 we found that “what matters most” to acutely admitted patients was mostly disease- and care-oriented. However, “why this matters most” topics were diverse, more personal, and often related to psychological well-being and relations. More than half of the included patients felt their treating doctor did not know what mattered most to them. Chapter 6 provides insight in the experiences and perspectives of older patients who visit the emergency department with a return visit within 30 days. The two major findings were that lack of clarity regarding waiting times and suboptimal discharge communication contributed to negative experiences. Chapter 7 shows that that few information about symptoms at the end of life is found in EHRs of deceased hospital patients. Symptoms are rarely measured with standardized methods in patients who died in Dutch Hospitals. In answer to our second research question, we conclude that when it comes to the elements of patients-centeredness that we measured (patient experiences and perspectives, what matters most, and quality indicators on physical/emotional comfort) there is also room for improvement.

In part III we described two studies on the topic timeliness. In chapter 8 we found that in the Netherlands there is a slight increase in the absolute number of older patients that visit the ED, and the total number of ED visits by older patients. However, this rise is consistent with overall population growth of older people. Chapter 9 shows that approximately one in five admitted patients occupying hospital beds did not meet the criteria for acute in-hospital stay or care. In other words: inappropriate bed occupancy. Most discharge delays were related to issues outside the immediate control of the hospital. In answer to our third research question we conclude that acute care for older patients might not always be timely