Healthcare Commissioning Forum

What is the effect on productivity by service redesign to reduce paediatric admissions?

If the programme set out in Focus on: emergency and urgent care pathway for children and young people were introduced across NHS England to reduce by 25% both the number of emergency admissions and the number of children and young people who present at emergency departments, then £129 million of benefits could be realised (first-year saving across 151 trusts).

This is based on reducing the number of tariff payments made per admitted patient (based on an average of £622 for overnight stay and an average of £565 for a zero length of stay, i.e. those who do not stay overnight – from Dr Foster Intelligence, 0–16 emergency data 2008/09).

For further information, please visit:  https://arms.evidence.nhs.uk/resources/qipp/29513/attachment

What is the impact on patient safety by service redesign to reduce paediatric admissions?

•   Standardised assessment, management and patient records based on implementation of guidelines to ensure safe, high-quality care across the pathway.
•   Common referral processes that are consistent across primary and secondary care.
•   Increased provision and utilisation of urgent care services outside hospital, ensuring that safe, high-quality care is delivered by competent trained professionals sharing a common governance framework.
•   Increased awareness among health professionals of the wider system that influences their work.

For further information, please visit:  https://arms.evidence.nhs.uk/resources/qipp/29513/attachment

Ambulatory or primary care sensitive conditions (ACSCs) are those for which hospital admission could be prevented by interventions in primary care (Bindman et al 1995; Purdy et al 2010c). At present, different sets of ACSCs are used in different situations. The most common ACSCs in England are based on a set of conditions initially derived to measure access to primary care in the United States; these were then refined for use in Australia (Agency for Healthcare Research and Quality 2001; NHS Institute for Innovation and Improvement 2007).

Some admissions (eg, those for dementia) may not be perceived to be avoidable, as the disease course is not significantly modifiable. However, the availability of more suitable alternatives to an acute hospital admission – for example, respite care or home care – can result in admission avoidance in the acute situation. This concept of an ACSC, which is dependent on availability and referral to an alternative service, is very different to the original American concept of the ACSC as a marker of availability of traditional clinical ambulatory or primary care.

Commissioners and other stakeholders will inevitably prioritise the conditions that  are of interest to them according to different criteria, which will vary depending on the viewpoint of the stakeholder. These priorities will also vary across health care systems, depending on the prevalence of the ACSCs and the economic and policy drivers in the local health care economy.

Recommendation:
   Commissioners need to be clear about which admissions they consider to be avoidable, what proportion of these admissions are avoidable, and how these admissions should be coded and measured.

For further information, please visit:  http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

A number of factors are associated with increased rates of admission, and are therefore important to consider when targeting interventions to reduce avoidable admissions.

Age

Age is a risk factor for emergency hospital admission, with babies or very young children and older people being at higher risk. However, it is important to recognise that only those aged 5 to 14 years have low risk. Figure 1 overleaf shows emergency admissions for one PCT in England, and illustrates the large number of admissions occurring in those under 65 years of age.

Social deprivation

There is evidence from the UK, North America and Europe that people who live in areas of socio-economic deprivation have higher rates of emergency admissions, after adjusting for other risk factors. In the UK, admission rates are significantly correlated with measures of social deprivation (Majeed et al 2000). Socio-demographic variables explain around 45 per cent of the variation in emergency admissions between GP practices, with deprivation more strongly linked to emergency than to elective admission (Reid et al 1999; Duffy et al 2002). Practices serving the most deprived populations have emergency admission rates that are around 60–90 per cent higher than those serving the least deprived populations (Blatchford et al 1999; Purdy et al 2010a).

Deprivation is also a risk factor for admission in Europe. Socio-economic risk factors for cardiovascular admission were evaluated in two large Scandinavian studies; both show that increasing socio-economic status – whether measured by employment status,
census variables, education, housing tenure or social capital – is associated with decreased emergency admission rates for coronary heart disease (Sundquist et al 2007; Tüchsen and Endahl 1999).

Morbidity levels

Higher levels of morbidity in a population are associated with higher levels of emergency admission. Admission rates are also correlated with chronic illness (Majeed et al 2000).

Higher levels of recorded morbidity and chronic disease in patients registered with GP practices have also been shown to be associated with higher rates of emergency admission from those practices (Bottle et al 2008; Donald and Ambery 2000).

Area of residence

Those who live in urban areas have higher rates of emergency hospital admission than those in rural areas; for example, we found a 16 per cent higher rate of asthma admissions for urban patients compared with rural patients (Purdy et al 2010a). What is uncertain
is whether these rates are lower due to better management in the community or because patients who live further from secondary care have more difficulty accessing services (O’Donnell 2000). We also found that those who live closer to A&E departments have higher rates of admission (for instance, a 12 per cent higher rate of admission for asthma), even after taking into account other risk factors, including living in an urban area (Purdy et al 2010a).

Ethnicity

Data on the impact of ethnicity on risk of emergency admission are fairly limited. Being from a minority ethnic group is associated with a higher risk of emergency admission (Bottle et al 2006). For example, in the UK, asthma admission rates for South Asian patients have been double those of white patients, and are also high for black patients (Gilthorpe et al 1998). Different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission among South Asian patients (Griffiths et al 2001).
 
Environmental factors

The evidence for environmental risk factors is variable across diseases. For example, air pollution and meteorological factors in the UK are probably less important in relation to cardiovascular admissions than they are in respiratory conditions such as COPD, where cold weather is associated with increased rates of admission (Maheswaran et al 2005; Moran et al 2000; Marno 2006).

Recommendation:
   Policy-makers should consider the impact of socio-economic deprivation and other socio-demographic factors when designing policy around admission rates.

For further information, please visit:  http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

High levels of admissions for ACSCs often indicate poor co-ordination between the different elements of the health care system, in particular between primary and secondary care. An emergency admission for an ACSC is a sign of the poor overall quality of care, even if the ACSC episode itself is managed well. The wide variation of emergency hospital admissions for ACSCs implies that they, and the associated costs for commissioners, can be reduced.

Patterns of emergency admissions for ACSCs

There were 5,135,794 emergency hospital admissions in England in 2009/10 (ie, April 2009 to March 2010), of which 816,433 (15.9 per cent) were for ACSCs. This is equivalent to 15.6 hospital admissions for ACSCs per 1,000 populations.

Age and sex

•   The proportion of hospital admissions for ACSCs was higher among very young children (14 per cent of all admissions were patients under 5 years old) and older people (30 per cent of all admissions were patients who were 75 years old and above).
•   The rate of admissions for ACSCs (lines in Figure 1) was slightly higher in males (15.9 per 1,000 populations) than in females (15.3 per 1,000 populations). The gap between males and females widened from 50–54 years old onwards. The gap was greatest in the 85-and-over age group (male/female gap at 20 per 1,000 populations). However, as the female population was larger in the very elderly age group (aged 80 and over), the actual number of admissions (bars in Figure 1) was larger in older females than in older males.

Condition

The leading causes of emergency admissions for ACSCs (see Figure 2 overleaf) were:
•   Influenza and pneumonia (13.4 per cent); chronic obstructive pulmonary disease (COPD) (13.2 per cent); ear, nose and throat infections (10.4 per cent); dehydration and gastroenteritis (10.4 per cent); and convulsions and epilepsy (9.5 per cent). These five conditions account for more than half (56.8 per cent) of all admissions for ACSCs.
•   The age distribution of admissions varied by condition. Admissions for acute conditions (eg, ear, nose and throat infections) were predominantly in young children; admissions for chronic conditions (eg, COPD, angina and congestive heart failure) were higher in older patients; admissions for vaccine-preventable conditions were higher in both the very young and the old.

Socio-economic

•   People from more deprived areas were more likely to be admitted for ACSCs.
•   The rate of emergency admissions in the population from the most deprived quintile (24.5 admissions per 1,000 population) was more than twice the rate in the population from the least deprived quintile (10.1 admissions per 1,000 population).
This strong positive association between ACSCs admissions and deprivation may be related to a range of factors in more deprived areas:
•   Higher prevalence of ACSCs, eg, higher prevalence of COPD in the most deprived communities in England (Simpson and Hippisley-Cox 2010)
•   Poorer access to primary care and preventive interventions, eg, socio-economic inequalities in the provision of health care to people with diabetes (Ricci-Cabello et al 2010)
•   Higher prevalence of presenting risk behaviour in patients, eg, smoking is more prevalent in deprived populations (Lakshman et al 2011) as well as being associated with hospital admissions for respiratory conditions (Purdy et al 2011).

For further information, please follow: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/data-briefing-emergency-hospital-admissions-for-ambulatory-care-sensitive-conditions-apr-2012.pdf