Guardianship Before and Following Hospitalization

Abstract

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Appendices

Appendix A: Disease Categories and ICD9 Codes Used for Matching

Disease categories	ICD9 code groups
Infectious disease
1. Urinary tract infection	599.0 Urinary Tract Infection
2. Other infection except pneumonia	008.0–008.8 Intestinal infection 050–059 Viral diseases 114 Coccidiodomycosis 038 Septicemia 995.91–999.92 Sepsis 572.0 Abscess of Liver 681–682 Cellulitis 696.1 Other psoriasis
Neoplasm related admission
3. Any neoplasm	140–239
Cardiac disease
4. Heart disease	401–405 Hypertensive disease 415–417 Diseases of pulmonary circulation 420–428 Other forms of heart disease 440 Atherosclerosis 458 Hypotension
5. Acute myocardial infarction	410 Acute myocardial infarction 786.50 Unspecified chest pain 786.79 Other chest pain 411.1–414.9 Other forms of chronic ischemic disease
Infarction or aneurysm
6. Cerebral infarction or stroke	431–438 Cerebrovascular disease excluding subarachnoid hemorrhage
7. Aneurysm, embolism or thrombosis	441–445 Aortic and other Aneurisms
Pulmonary disease
8. Pneumonia and bronchitis	466 Acute Bronchitis 480–486 Pneumonia 507 Pneumonitis due to solids or liquids
9. Chronic pulmonary disease	490 Bronchitis NOS 491–492.8 Chronic Bronchitis and Emphysema 494 Bronchiectasis 496 Chronic airway obstruction NOS 518 Pulmonary Failure and Collapse
Gastrointestinal disease
10. Esophagitis	528 Disease of oral soft tissue 530 Esophagitis / ulcer of Esophagus
11. Pancreatitis	577 Acute and chronic pancreatitis
12. Enteritis and colitis	555–558 Gastroenteritis and colitis 562 Diverticulosis 567 Peritonitis 568–569 Other disorders of Peritoneum 578 Gastrointestinal Hemorrhage – other
13. Hernia of the abdominal cavity	550–553 Hernia
Liver disease
14. Cirrhosis and other liver disease	571 Cirrhosis of Liver 572.2 Hepatic Encephalopathy 789.59 Other Ascites
Renal disease
15. Acute and chronic renal failure	583 Nephritis 584.5–584.9 Acute renal failure 585. Chronic kidney disease 586–587 Renal failure or sclerosis, unspecified 588 Disorders resulting from impaired renal function
16. Diabetes	250 Diabetes
Orthopedic
17. Osteoarthritis and Spondylopathies	715–716 Osteoarthritis and related disorders 719 Pain in joint 720–721 Spondylitis 724.2 Lumbago 724.4 Thoracic or lumbosacral neuritis 730 Osteomyelitis 733.99 Other dx of bone or cartilage 781 Abnormality of gait
18. Fracture	820–829 Fracture of lower limb 843–845 Sprain of lower limb
Neurocognitive or neuropsychiatric
19. Any dementia, schizophrenia, substance use	290, 293, 294 Dementia
	295–298 Schizophrenia
	303–305 Substance Use
Other
20. Syncope	780.2 Syncope and collapse
21. Adverse drug reaction	960–973 Poisoning by drugs 995.2 Other adverse drug reaction 359.4 Toxic Myopathy 333.92 Neuroleptic Malignant Syndrome
22. Surgical Aftercare	V55 Attention to artificial openings V58 Aftercare following procedures/surgery
23. Anemia	280–285 Anemia

Appendix B: Disease Categories Frequency

Type	Cohort (%)	Comparison (%)
Infectious disease
Urinary tract Infection	3.8	3.8
Other Infection except pneumonia	8.7	8.7
Neoplasm	4.8	4.8
Cardiac disease
Heart disease	9.1	9.1
Acute myocardial infarction	3.4	3.4
Infarction or aneurysm
Cerebral infarction or stroke	3.8	3.8
Aneurysm, embolism or thrombosis	1.4	1.4
Pulmonary disease
Pneumonia and bronchitis	9.6	9.6
Chronic pulmonary disease	2.4	2.4
Gastrointestinal disease
Esophagitis	1.4	1.4
Pancreatitis	2.9	2.9
Enteritis and colitis	4.3	4.3
Hernia of the abdominal cavity	1.0	1.0
Liver disease
Cirrhosis and other liver disease	2.9	2.9
Renal disease
Acute and chronic renal failure	3.8	3.8
Diabetes	2.4	2.4
Orthopedic
Osteoarthritis and spondylopathies	5.3	5.3
Fracture	2.9	2.9
Neurocognitive or neuropsychiatric
Dementia	13.9	13.9
Schizophrenia	1.4	1.4
Substance use	0.5	0.5
Other
Syncope	2.4	2.4
Adverse drug reaction	2.4	2.4
Surgical aftercare	2.4	2.4
Anemia	2.9	2.9