Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians

Potentially avoidable hospitalizations for older patients transferred from long-term care hospitals: a nationwide cross-sectional analysis of potential healthcare consequences

Multiple chronic disorders and disabilities among older patients in long term care hospitals (LTCH) tends to increase the healthcare burden by causing overcrowding, particularly in emergency departments. Therefore, access to timely and adequate healthcare for LTCH patients is an increasingly important issue, and potentially avoidable hospitalizations (PAHs) and hospitalizations during non-office hours can result as indicators of emergency department overcrowding. The study aimed to evaluate PAHs and hospitalizations during non-office hours in emergency departments for older patients transferred from LTCH compared to patients living at home. We performed a cross-sectional study using the National Emergency Department Information System database from January 2018 to December 2019, in South Korea, with older patients (≥ 65 years) who visited nationwide emergency departments. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for indicators of overcrowding as PAHs and hospitalizations during non-office hours were calculated by logistic regression. Among the 2,177,663 older patients who visited the emergency departments, 98,434 patients were living in LTCH and 2,079,229 patients were living at home. The older patients living in LTCH was associated with PAHs (aOR: 1.90, 95% CI 1.87-1.94) and hospitalizations during non-office hours (aOR: 1.76, 95% CI 1.73-1.78). LTCH patients showed more hospital visits, extended stay in the emergency department, greater prevalence of chronic diseases, greater rates of transfer as well as higher admission rates and mortality as compared to the patients living at home. The LTCH older patients were associated with the indicators of emergency department overcrowding, which impacts health care quality in hospitals. Introduction of policy and training programs for LTCH staff are recommended to manage vulnerable groups in advance.

Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents

OBJECTIVE

To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs).

DESIGN

We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers.

SETTING AND PARTICIPANTS

We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs.

METHODS

We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision.

RESULTS

Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13).

CONCLUSIONS AND IMPLICATIONS

PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study

BACKGROUND

Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics.

METHODS

We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement.

RESULTS

Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department.

INTERPRETATION

Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research.

STUDY REGISTRATION

ID ISRCTN22901977.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

INTRODUCTION

Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.

OBJECTIVES

Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC.

METHODS AND ANALYSIS

A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Hospitalizations for Ambulatory Care Sensitive Conditions in a Large City of Japan: a Descriptive Analysis Using Claims Data

BACKGROUND

Hospitalization for ambulatory care sensitive conditions (ACSCs) is an indicator of the quality of primary care in different health systems. In Japan, where patients can choose any healthcare facility with universal health coverage (UHC), data on these admissions are unknown.

OBJECTIVE

To describe the current situation of ACSC admissions in a city of Japan.

DESIGN

Retrospective observational study using claims data.

PARTICIPANTS

Beneficiaries aged 0-74 years of the National Health Insurance (NHI) program in a large city in the Greater Tokyo Area. We extracted ACSC admissions from all inpatient claims between April 2013 and March 2017.

MAIN MEASURES

We calculated age- and sex-specific annual ACSC admission rates for three categories: acute, chronic, and vaccine-preventable. We estimated the age-adjusted admission rates by ACSC category according to administrative districts and rate ratios using Poisson regression models. We also estimated medical expenditures and lengths of stay for ACSC admissions.

KEY RESULTS

Of 91,350 hospitalization episodes, we identified 7666 (8.4%) that were ACSC admissions. Males had higher annual ACSC admission rates than females (p < 0.001), especially for chronic ACSCs. Admission rates were lowest in those aged 15-39 years and higher in the youngest (0-4 years) and oldest (70-74 years) age groups. Age-adjusted chronic ACSC admission rates were lower in a newly developed area (rate ratio [RR]: 0.79, 95% confidence interval [CI]: 0.71-0.87) and higher in a residential area (RR: 1.14, 95% CI: 1.04-1.24) than in the center of the city. Total medical expenditures for all ACSC admissions accounted for 5.8% of the total inpatient expenditures of NHI in the city.

CONCLUSIONS

ACSC admission rates in Japan were higher for males than for females and showed a U-shaped trend in terms of age, as in other countries with UHC, and deferred by region. This study provided possible factors to reduce ACSC admissions.

Predicting Health Risks of Adult Asthmatics Susceptible to Indoor Air Quality Using Improved Logistic and Quantile Regression Models

The increasing global patterns for asthma disease and its associated fiscal burden to healthcare systems demand a change to healthcare processes and the way asthma risks are managed. Patient-centered health care systems equipped with advanced sensing technologies can empower patients to participate actively in their health risk control, which results in improving health outcomes. Despite having data analytics gradually emerging in health care, the path to well established and successful data driven health care services exhibit some limitations. Low accuracy of existing predictive models causes misclassification and needs improvement. In addition, lack of guidance and explanation of the reasons of a prediction leads to unsuccessful interventions. This paper proposes a modeling framework for an asthma risk management system in which the contributions are three fold: First, the framework uses a deep learning technique to improve the performance of logistic regression classification models. Second, it implements a variable sliding window method considering spatio-temporal properties of the data, which improves the quality of quantile regression models. Lastly, it provides a guidance on how to use the outcomes of the two predictive models in practice. To promote the application of predictive modeling, we present a use case that illustrates the life cycle of the proposed framework. The performance of our proposed framework was extensively evaluated using real datasets in which results showed improvement in the model classification accuracy, approximately 11.5–18.4% in the improved logistic regression classification model and confirmed low relative errors ranging from 0.018 to 0.160 in quantile regression model.

Proactive Health Support: a randomised controlled trial of telephone-based self-management support for persons at risk of hospital admission

BACKGROUND

Persons with frequent hospital admissions have a disease burden that may exceed their self-management skills. The evidence base of telephone-based interventions to support self-management is poor with mixed results. The aim of this study is to evaluate the effect of Proactive Health Support (PaHS): telephone-based self-management support for persons with risk of hospitalizations.

METHODS

This study is a national randomised controlled trial of PaHS versus usual universal tax-funded healthcare. Participants were persons at risk of emergency hospital admissions. The intervention began with a physical start-up session followed by telephone sessions of self-management support. The two co-primary outcomes were Health-Related Quality of Life (HRQoL) (Mental Health Component Summary Score of SF36v2) analysed with mixed models and hospital admissions analysed with Poisson regression at 6 months. Secondary outcomes were at 3- and 12-month follow-up and disease subgroup analyses.

RESULTS

During the study period, 6,402 persons were randomised (3,190 intervention, 3,212 control). HRQoL was significantly improved at 6 months (Est. 1.4992, P = <0.0001) and at 3 and 12 months on all 10 scales. There was no overall effect on hospital admissions at 6 months with an adjusted estimate of 0.0074 (P = 0.8691). Persons with diabetes had significant improvement of HRQoL and reduced hospital admissions.

CONCLUSIONS

The PaHS intervention improved HRQoL for all participants and reduced hospital admissions for persons with diabetes only.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Portuguese Primary Healthcare and Prevention Quality Indicators for Diabetes Mellitus - A Data Envelopment Analysis

BACKGROUND

Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings).

METHODS

We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care.

RESULTS

A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation.

CONCLUSION

Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.

Interventions to Prevent Potentially Avoidable Hospitalizations: A Mixed Methods Systematic Review

Background

The demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services.

Methods and Results

A mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations.

Conclusions

The syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.

Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018

Objective

This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China.

Methods

In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations.

Results

From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased.

Conclusions

Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08275-w.

Emergency Departments as Care Providers for Patients with Cardiac Ambulatory Care Sensitive and Mental Health Conditions: Qualitative Interview and Focus Group Study with Patients and Physicians

Mental health conditions are frequent among patients with somatic illnesses, such as cardiac diseases. They often remain undiagnosed and are related to increased utilization of outpatient services, including emergency department care. The objective of this qualitative study was to investigate the significance of the emergency department in the patients' course of treatment and from the physicians' perspective. An improved understanding of the subjective needs of this specific patient group should provide hints for targeted treatment. This study is part of the prospective EMASPOT study, which determined the prevalence of mental health conditions in emergency department patients with cardiac ambulatory care sensitive conditions. The study on hand is the qualitative part, in which 20 semi-structured interviews with patients and a focus group with six ED physicians were conducted. Data material was analyzed using the qualitative content analysis technique, a research method for systematically identifying themes or patterns. For interpretation, we used the "typical case approach". We identified five "typical patient cases" that differ in their cardiac and mental health burden of disease, frequency and significance of emergency department and outpatient care visits: (1) frequent emergency department users with cardiac diseases and mental health conditions, (2) frequent emergency department users without cardiac diseases but with mental health conditions, (3) needs-based emergency department users with cardiac diseases; (4) targeted emergency department users as an alternative to specialist care and (5) patients surprised by initial diagnose of cardiac disease in the emergency department. While patients often perceived the emergency department visit itself as a therapeutic benefit, emergency department physicians emphasized that frequent examinations of somatic complaints can worsen mental health conditions. To improve care, they proposed close cooperation with the patients' primary care providers, access to patients' medical data and early identification of mental health conditions after cardiac diagnoses, e.g., by an examination tool.

Characterizing Potentially Preventable Hospitalizations of High-Cost Patients in Rural China

Introduction

High-cost patients are characterized by repeated hospitalizations, and inpatient cost accounts for a large proportion of their total health care spending. This study aimed to assess the occurrence and costs of potentially preventable hospitalizations and explore contributing factors among high-cost patients in rural China.

Methods

We examined a population-based sample of patients using the 2016 New Rural Cooperative Medical Scheme in Dangyang city, China. Eighteen thousand forty-three high-cost patients were identified. A validated tool and logistic regression analysis were used to determine preventable hospitalizations and their patient-level and supply-side factors.

Results

High-cost patients were older (average age of 54 years) than non-high-cost patients (50 years) and more likely to come from poverty-stricken families. The occurrence of preventable hospitalization was 21.65% among high-cost patients. The proportion of preventable inpatient cost in total inpatient and outpatient expenditure among high-cost patients (5.81%) was lower than that of non-high-cost patients (7.88%) but accounted for 75.87% of the overall preventable inpatient cost. High-cost patients with more hospitalizations were more likely to experience preventable hospitalization, and those with heart failure, COPD, diabetes and mixed conditions were at a higher risk of preventable hospitalization, while those with more outpatient visits were less likely to show preventable hospitalization.

Conclusions

The occurrence of preventable hospitalization among high-cost patients in rural China was sizeable. The preventable inpatient cost of the overall population was concentrated among high-cost patients. Interventions such as improving preventive care and disease management targeting high-cost patients within counties may improve patients' health outcomes and quality of life and reduce overall preventable inpatient cost.

Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations

Background: Hospitalizations of nursing home residents are associated with various health risks. Previous research indicates that, to some extent, hospitalizations of this vulnerable population may be inappropriate and even avoidable. This study aimed to develop a consensus list of hospital discharge diagnoses considered to be nursing home-sensitive, i.e., avoidable. Methods: The study combined analyses of routine data from six statutory health insurance companies in Germany and a two-stage Delphi panel, enhanced by expert workshop discussions, to identify and corroborate relevant diagnoses. Experts from four different disciplines estimated the proportion of hospitalizations that could potentially have been prevented under optimal conditions.   Results: We analyzed frequencies and costs of data for hospital admissions from 242,236 nursing home residents provided by statutory health insurance companies. We identified 117 hospital discharge diagnoses, which had a frequency of at least 0.1%. We recruited experts (primary care physicians, hospital specialists, nursing home professionals and researchers) to estimate the proportion of potentially avoidable hospitalizations for the 117 diagnoses deemed avoidable in two Delphi rounds (n=107 in Delphi Round 1 and n=96 in Delphi Round 2, effective response rate=91%). A total of 35 diagnoses with high and consistent estimates of the proportion of potentially avoidable hospitalizations were identified as nursing home-sensitive. In an expert workshop (n=16), a further 25 diagnoses were discussed that had not reached the criteria, of which another 23 were consented to be nursing home-sensitive conditions. Extrapolating the frequency and mean costs of these 58 diagnoses to the national German context yielded total potentially avoidable care costs of €768,304,547, associated with 219,955 nursing home-sensitive hospital admissions. Conclusion: A total of 58 nursing home-relevant diagnoses (ICD-10-GM three-digit level) were classified as nursing home-sensitive using an adapted Delphi procedure. Interventions should be developed to avoid hospital admission from nursing homes for these diagnoses.

Avoidable hospitalizations and access to primary care: comparisons among Italians, resident immigrants and undocumented immigrants in administrative hospital discharge records

BACKGROUND

Immigrants face multiple barriers in accessing healthcare; however, empirical assessment of access presents serious methodological issues, and evidence on undocumented immigrants is scant and based mainly on non-representative samples. We examine avoidable hospitalization (AH) as an indicator of poor access to primary care (PC) in Italy, where a universal healthcare system guarantees access but fails to assign general practitioners to undocumented immigrants.

METHODS

Using anonymized national hospital discharge records in 2019, undocumented immigrants were identified through an administrative financing code. Potential effects of poor access to PC were measured by focusing on the incidence of AH, differentiated among chronic, acute and vaccine-preventable conditions, comparing Italian citizens, documented (foreign nationals with residence permits) and undocumented immigrants. We estimated odd ratios (ORs) through logistic regression models, controlling for individual and contextual confounders.

FINDINGS

Compared with Italians, undocumented and documented immigrants adjusted odd ratios (OR) for the risk of AH were 1·422 (95% CI 1·322-1·528) and 1·243 (95% CI 1·201-1·287), respectively. Documented immigrants showed ORs not significantly greater than 1 for AH due to chronic diseases compared with Italians, while undocumented immigrants registered higher adjusted OR for all AH categories - chronic (OR 1·187; 95% CI 1·064-1·325), acute (OR 1·645; 95% CI 1·500-1·803) and vaccine-preventable (OR 2·170; 95% CI 1·285-3·664).

INTERPRETATION

Documented and undocumented immigrants face considerably higher risk of AH compared to Italians. Considering the burden of AHs, access to PC (including preventive and ambulatory care) should be provided to undocumented immigrants, and additional barriers to care for all immigrants should be further explored.

FUNDING

None.

Predicting hospitalisations related to ambulatory care sensitive conditions with machine learning for population health planning: derivation and validation cohort study

OBJECTIVE

To predict older adults' risk of avoidable hospitalisation related to ambulatory care sensitive conditions (ACSC) using machine learning applied to administrative health data of Ontario, Canada.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study was conducted on a large cohort of all residents covered under a single-payer system in Ontario, Canada over the period of 10 years (2008-2017). The study included 1.85 million Ontario residents between 65 and 74 years old at any time throughout the study period.

DATA SOURCES

Administrative health data from Ontario, Canada obtained from the (ICES formely known as the Institute for Clinical Evaluative Sciences Data Repository.

MAIN OUTCOME MEASURES

Risk of hospitalisations due to ACSCs 1 year after the observation period.

RESULTS

The study used a total of 1 854 116 patients, split into train, validation and test sets. The ACSC incidence rates among the data points were 1.1% for all sets. The final XGBoost model achieved an area under the receiver operating curve of 80.5% and an area under precision-recall curve of 0.093 on the test set, and the predictions were well calibrated, including in key subgroups. When ranking the model predictions, those at the top 5% of risk as predicted by the model captured 37.4% of those presented with an ACSC-related hospitalisation. A variety of features such as the previous number of ambulatory care visits, presence of ACSC-related hospitalisations during the observation window, age, rural residence and prescription of certain medications were contributors to the prediction. Our model was also able to capture the geospatial heterogeneity of ACSC risk in Ontario, and especially the elevated risk in rural and marginalised regions.

CONCLUSIONS

This study aimed to predict the 1-year risk of hospitalisation from ambulatory-care sensitive conditions in seniors aged 65-74 years old with a single, large-scale machine learning model. The model shows the potential to inform population health planning and interventions to reduce the burden of ACSC-related hospitalisations.

Avoidable hospitalization after family physician and rural health insurance: interrupted time series and regression analyses, Tehran province, Iran

BACKGROUND

Studying the effect of primary health care development when simultaneously implemented with health insurance schemes assesses effectiveness and use of health care services and gives us insight on how to develop such interventions in different countries.

AIM

To analyze the impact of health insurance and the family physician program on total hospitalizations, and the relation between avoidable hospitalizations and access to family physicians among the rural population in Iran.

METHODS

We conducted an interrupted time series (ITS) analysis of monthly hospitalization rates between the years of 2003 and 2014 to assess the immediate and gradual effects of these reforms on total hospitalization rates in the rural areas of Tehran province. In addition, we used a sample of 22 570 hospitalizations between 2006 and 2013 to develop a logistic regression model to measure the association between access to a family physician and avoidable hospitalizations.

FINDINGS

ITS analysis showed that there was an immediate increase of about 1.96 hospitalizations per 1000 inhabitants (P<0.0001, CI=1.58, 2.34) hospitalization rates after the reforms. This was followed by a significant increase of about 0.089 per 1000 inhabitants (P<0.0001, CI=0.07, 0.1). Hospitalization increase continued up to four years after the policy implementation. Following that, hospitalization rates decreased among the rural population (a decrease of 0.066 per 1000, P<0.0001, CI=-0.084, -0.048). Studying the hospitalizations that occurred between 2006 and 2013 showed that there were 4106 avoidable hospitalizations from among a sample of 22 570 hospitalizations. Results of logistic regression models including gender, age and access to family physician variables showed that there was no statistical relation between access to a family physician and avoidable hospitalizations.

CONCLUSION

Reforms had access effect and caused increased hospital services uses in people with unmet needs. Also the reforms did not decrease avoidable hospitalizations, and therefore had no efficiency effect.

Measuring medically unjustified hospitalizations in Switzerland

Background

Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics.

Methods

The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse).

Results

Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered.

Conclusion

We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07569-3.

Unseen patterns of preventable emergency care: Emergency department visits for ambulatory care sensitive conditions

Objective

Admissions for ambulatory care sensitive conditions (ACSCs) are often used to measure potentially preventable emergency care. Visits to emergency departments with ACSCs may also be preventable care but are excluded from such measures if patients are not admitted. We established the extent and composition of this preventable emergency care.

Methods

We analysed 1,505,979 emergency department visits (5% of the national total) between 1 April 2015 and 31 March 2017 at six hospital Trusts in England, using International Classification of Diseases diagnostic coding. We calculated the number of visits for each ACSC and examined the proportions of these visits that did not result in admission by condition and patient characteristics.

Results

11.1% of emergency department visits were for ACSCs. 55.0% of these visits did not result in hospital admission. Whilst the majority of ACSC visits were for acute rather than chronic conditions (59.4% versus 38.4%), acute visits were much more likely to conclude without admission (70.3% versus 33.4%). Younger, more deprived and ethnic minority patients were less likely to be admitted when they visited the emergency department with an ACSC.

Conclusions

Over half of preventable emergency care is not captured by measures of admissions. The probability of admission at a preventable visit varies substantially between conditions and patient groups. Focussing only on admissions for ACSCs provides an incomplete and skewed picture of the types of conditions and patients receiving preventable care. Measures of preventable emergency care should include visits in addition to admissions.

Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China

The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.

Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation

BACKGROUND

Patient experience is an important outcome and indicator of healthcare quality, and patient reported experiences are key to improving quality of care. While patient experience in emergency departments (EDs) has been reported in research, there is limited evidence about patients' specific experiences with primary care services located in or alongside EDs. We aim to identify theories about patient experience and acceptability of being streamed to a primary care clinician in an ED.

METHODS

Using theories from a rapid realist review as a basis, we interviewed 24 patients and 106 staff members to generate updated theories about patient experience and acceptability of streaming to primary care services in EDs. Feedback from 56 stakeholders, including clinicians, policymakers and patient and public members, as well as observations at 13 EDs, also contributed to the development of these theories, which we present as a programme theory.

RESULTS

We found that patients had no expectations or preferences for which type of clinician they were seen by, and generally found being streamed to a primary care clinician in the ED acceptable. Clinicians and patients reported that patients generally found primary care streaming acceptable if they felt their complaint was dealt with suitably, in a timely manner, and when clinicians clearly communicated the need for investigations, and how these contributed to decision-making and treatment plans.

CONCLUSIONS

From our findings, we have developed a programme theory to demonstrate that service providers can expect that patients will be generally satisfied with their experience of being streamed to, and seen by, primary care clinicians working in these services. Service providers should consider the potential advantages and disadvantages of implementing primary care services at their ED. If primary care services are implemented, clear communication is needed between staff and patients, and patient feedback should be sought.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México

OBJECTIVES

To estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010-2017.

METHODS

Secondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression.

RESULTS

For the period 2010-2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015-2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina.

CONCLUSIONS

AH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

Antibiotic prescribing rate after optimal near-patient C-reactive protein testing in acutely ill children presenting to ambulatory care (ARON project): protocol for a cluster-randomized pragmatic trial

INTRODUCTION

Children become ill quite often, mainly because of infections, most of which can be managed in the community. Many children are prescribed antibiotics which contributes to antimicrobial resistance and reinforces health-seeking behaviour. Point-of-care C reactive protein (POC CRP) testing, prescription guidance and safety-netting advice can help safely reduce antibiotic prescribing to acutely ill children in ambulatory care as well as save costs at a systems level.

METHODS AND ANALYSIS

The ARON (Antibiotic prescribing Rate after Optimal Near-patient testing in acutely ill children in ambulatory care) trial is a pragmatic cluster randomized controlled superiority trial with a nested process evaluation and will assess the clinical and cost effectiveness of a diagnostic algorithm, which includes a standardised clinical assessment, a POC CRP test, and safety-netting advice, in acutely ill children aged 6 months to 12 years presenting to ambulatory care. The primary outcome is antibiotic prescribing at the index consultation; secondary outcomes include clinical recovery, reconsultation, referral/admission to hospital, additional testing, mortality and patient satisfaction. We aim to recruit a total sample size of 6111 patients. All outcomes will be analysed according to the intent-to-treat approach. We will use a mixed-effect logistic regression analysis to account for the clustering at practice level.

ETHICS AND DISSEMINATION

The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version), the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 November 2020 from the Ethics Committee Research of University Hospitals Leuven under reference S62005. We will ensure that the findings of the study will be disseminated to relevant stakeholders other than the scientific world including the public, healthcare providers and policy-makers. The process evaluation that is part of this trial may provide a basis for an implementation strategy. If our intervention proves to be clinically and cost-effective, it will be essential to educate physicians about introducing the diagnostic algorithm including POC CRP testing and safety-netting advice in their daily practice.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04470518. Protocol V.2.0 date 2 October 2020. (Pre-results).

Identifying patient characteristics associated with potentially redirectable paramedic transported emergency department visits in Ontario, Canada: a population-based cohort study

OBJECTIVE

Paramedic redirection from emergency department (ED) to subacute centres may be more beneficial for some patients, though little is known about which patients are potentially appropriate. We examined whether patient characteristics were associated with ED visits when the main intervention was suitable to be performed in a subacute centre.

METHODS

We conducted a retrospective observational study using the National Ambulatory Care Reporting System from 2014 to 2018 in Ontario, Canada. We included all adult patients transported by paramedics and had a main physician intervention recorded. We used results of a RAND/UCLA modified Delphi study to categorise patients into either ED or a subacute care (urgent care and/or general practice centre) based on their main intervention. An independent logistic regression model was analysed for each subacute centre.

RESULTS

A total of 2 394 072 ED visits were included; 59% of ED interventions were categorised as 'urgent care', 27% 'ED only', 9% either 'urgent care' or 'general practice' and 5% had an intervention not previously classified. ED visits suitable for 'general practice' had the highest percentage of patients discharged, while 'ED only' had the lowest. Lower medical acuity, younger age, time of triage in evening and overnight, and discharged from ED were independently associated with both subacute centres. 'Urgent care' visits/interventions were associated with an ED main diagnosis of the respiratory system (OR 3.49), while 'general practice' visits were associated with mental health disorders (OR 9.85) and injury/poison/consequences of external causes (OR 3.38).

CONCLUSIONS

The majority of ED visits had a main intervention that could have potentially been conducted in a subacute centre. We identified characteristics and diagnostic patterns associated with ED visits when the main intervention was categorised as a subacute centre intervention. This study contributes knowledge to inform which patients are potentially appropriate for paramedic redirection.

Redefining avoidable and inappropriate admissions

OBJECTIVES

Focusing on policy discourse in the United Kingdom, we examine the chain of causation that is characteristic of the ways in which the concepts of avoidability and inappropriateness are defined and used in these contexts. With a particular focus on diabetes complications, we aim to elucidate the way in which avoidable admission to hospital is conceptualised, measured, and applied to policy development and implementation and build a more inclusive model of identification as a basis for further research in this area.

STUDY DESIGN

Discourse analysis was used in combination with a scoping review.

METHODS

We searched the online databases of the UK Houses of Parliament Hansard, Official reports of the Northern Ireland Assembly and transcripts of the Scottish Parliament in October 2021. We also conducted an electronic search in October 2021 on MEDLINE, PubMed, Google Scholar, EMBASE, CINAHL and The Cochrane Library to review the available literature. In addition, an analysis of policies in place in Scotland, England and Northern Ireland relating to urgent diabetes care was conducted.

RESULTS

'Avoidable' and 'inappropriate' hospital admissions are categories used in health policy and practice internationally as ways of identifying targets for interventions intending to reduce the burden of care. Diabetes mellitus is a chronic condition that is often seen as a costly and avoidable use of health care services and so is a frequent target of such policies. Avoidable admission is interpreted as having a very long chain of causation. The assumption is that people requiring unscheduled hospital admission could have taken steps to prevent the onset of diabetes, or associated complications, arising in the first place. Definitions focus on primary and secondary prevention and largely place responsibility on the individual and their behaviour rather than on structural or social factors. Inadequate or inappropriate care prehospital or in the emergency department is seldom considered as a potential cause of avoidable admissions. Procedural definitions of avoidable admission are proposed whereby health care professionals and people living with diabetes collaborate to identify avoidable admissions in clinical audit rather than using statistical rates of avoidable admission within isolation in policy development and implementation.

CONCLUSIONS

Avoidability and inappropriateness are characteristics of cases in which conduct of the individual or attendant health care professionals was a proximate cause of hospital admission, and but for such conduct, admission could have been avoided. This process of definition seeks to provide a basis for contextualised and considered evaluation of where there are problems in care and where there are reasonable opportunities for prevention.

Nursing home-sensitive conditions: analysis of routine health insurance data and modified Delphi analysis of potentially avoidable hospitalizations

Background: Hospitalizations of nursing home residents are associated with various health risks. Previous research indicates that, to some extent, hospitalizations of this vulnerable population may be inappropriate and even avoidable. This study aimed to develop a consensus list of hospital discharge diagnoses considered to be nursing home-sensitive, i.e., avoidable. Methods: The study combined analyses of routine data from six statutory health insurance companies in Germany and a two-stage Delphi panel, enhanced by expert workshop discussions, to identify and corroborate relevant diagnoses. Experts from four different disciplines estimated the proportion of hospitalizations that could potentially have been prevented under optimal conditions.  Results: We analyzed frequencies and costs of data for hospital admissions from 242,236 nursing home residents provided by statutory health insurance companies. We identified 117 hospital discharge diagnoses, which had a frequency of at least 0.1%. We recruited experts (primary care physicians, hospital specialists, nursing home professionals and researchers) to estimate the proportion of potentially avoidable hospitalizations for the 117 diagnoses deemed avoidable in two Delphi rounds (n=107 in Delphi Round 1 and n=96 in Delphi Round 2, effective response rate=91%). A total of 35 diagnoses with high and consistent estimates of the proportion of potentially avoidable hospitalizations were identified as nursing home-sensitive. In an expert workshop (n=16), a further 25 diagnoses were discussed that had not reached the criteria, of which another 23 were consented to be nursing home-sensitive conditions. Extrapolating the frequency and mean costs of these 58 diagnoses to the national German context yielded total potentially avoidable care costs of €768,304,547, associated with 219,955 nursing home-sensitive hospital admissions. Conclusion: A total of 58 nursing home-relevant diagnoses (ICD-10-GM three-digit level) were classified as nursing home-sensitive using an adapted Delphi procedure. Interventions should be developed to avoid hospital admission from nursing homes for these diagnoses.

Hospitalization for ambulatory care sensitive conditions: What conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population's demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.

Analysis of Emergency Department Utilization in Medicaid Expansion and Non-expansion States

Introduction

The Affordable Care Act has been debated since its initial enactment over a decade ago. One of the primary topics for discussion has been Medicaid expansion, which has created a schism across the United States. The effects of Medicaid expansion largely remain unclear. The purpose of this report is to elucidate how Medicaid expansion has impacted emergency department (ED) utilization by analyzing Medicaid expansion and non-expansion states to determine who visited the ED and the reason for the visit.

Methods

We conducted a retrospective analysis using de-identified electronic medical record (EMR) data from 56,423 patients and 33 different hospitals (18 Medicaid non-expansion and 15 Medicaid expansion) who visited the ED in 2019. We used geographical demographics and insurance status to categorize patients who visited the ED and ambulatory care sensitive conditions (ACSC) to identify the reasons for the visit. Logistic regression and chi-square analysis were used to analyze the data.

Results

We observed a significant relationship between Medicaid expansion and geographic region such that patients living in rural or semirural regions likely resided in Medicaid non-expansion states. Patients using self-pay were more likely to live in a Medicaid non-expansion state than a Medicaid expansion state (32.3% vs. 21.5%, p-value < 0.0001). Finally, there were no significant differences between the top five ACSC for Medicaid expansion and Medicaid non-expansion states but living in an expansion state was significantly (p < 0.01) related to being diagnosed with an ACSC (OR, 1.056; 95% CI, 1.013-1.100).

Conclusion

In conclusion, Medicaid expansion was associated with differences in the use of medical resources. Patients using Medicaid insurance who reside in Medicaid expansion states preferentially use the ED. Geographical location does play a role in ED utilization and ambulatory care sensitive condition diagnoses in patients. Despite these findings, the full effects of Medicaid expansion on ED utilization require further investigation. However, our research indicates that Medicaid expansion is not the singular solution in decreasing ED utilization and healthcare costs.

Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care

INTRODUCTION

Low- and middle-income countries (LMICs) bear a high proportion of the global morbidity and mortality caused by COPD. Increased exposure to risk factors throughout life (e.g. malnutrition, indoor and outdoor air pollution, and smoking) is associated with higher COPD prevalence in LMICs and the lack of treatment availability increases avoidable harm.

AREAS COVERED

This review covers the epidemiology and burden of COPD in LMICs, and challenges and recommendations related to health-care systems, prevention, diagnosis, and treatment. Main challenges are related to under-resourced health-care systems (such as limited availability of spirometry, rehabilitation, and medicines). Lack of policy and practical local guidelines on COPD diagnosis and management further contribute to the low diagnostic and treatment rates. In the absence of, or limited number of respiratory specialists, primary care practitioners (general practitioners, nurses, pharmacists, physiotherapists, and community health workers) play an even more pivotal role in COPD management in LMICs.

EXPERT OPINION

Raising awareness on COPD, educating health-care workers, patients, and communities on cost-effective preventive measures as well as improving availability, affordability and proper use of diagnostic and pharmacological and non-pharmacologic treatment in primary care are the key interventions needed to improve COPD prevention, diagnosis, and care in LMICs.

Predicting Individual Risk of Emergency Hospital Admissions - A Retrospective Validation Study

Purpose

A high number of hospital admissions may indicate poor general health and less than optimal health care across sectors. To prevent hospital admissions, previous studies have focused on predicting readmissions relating to a defined index admission and specific condition, whereas generic models suited for community-dwelling persons are lacking. The aim of this study was to validate a generic model that predicted risk of emergency hospital admission within the following three months and to investigate regional variation.

Materials and Methods

This study is an observational register-based validation study of a prediction model. The prediction model was based on a population of frail elderly, persons with non-communicable diseases, and persons with three emergency hospital admissions using information about diagnoses and hospital contacts. The prediction model consisted of two stages. In the first stage, covariate associations to admissions are estimated from observed data in one year. In the second stage, admissions are predicted in the coming three months based on observed estimations from the first stage. The validity of the model was calculated by comparing predicted and observed admissions from August 1st to October 31st, 2016.

Results

The study included 112,026 persons. In nationwide data, area under the curve (AUC) was 0.7742 (95% CI 0.7698–0.7786), and the positive predictive value was 52% for the 99th percentile (the top 1%). AUC varied between regions from 0.6914 in Southern Denmark (95% CI 0.6779–0.7049) to 0.8224 (95% CI 0.8064–0.8384) in North Denmark. AUC was higher with nationwide data compared to regional.

Conclusion

The model performed satisfactorily in predicting individual risk of emergency hospital admission.

Measuring the impact of a Chronic Obstructive Pulmonary Disease Community Respiratory Programme on emergency admissions to hospital: a controlled interrupted time series analysis

BACKGROUND

A community respiratory service was implemented in the North West of Glasgow (NW) in January 2013, as part of the Reshaping Care for Older People programme (RCOP). This study aimed to measure the impact of the service on older people's emergency admissions (EAs) to hospital.

METHODS

EAs to hospital with a primary diagnosis of COPD (COPD EAs) per 1,000 population aged 65 years+ in NW were compared before and after onset of the service with a 6-month phase-in period, using segmented linear regression. South and North East Glasgow (S + NE) was the control-an area with no such service in place. The model adjusted for the rate of all-cause EAs to control for the impact of other localised RCOPP initiatives. Autoregressive terms and a Fourier term to adjust for seasonality were included in the model.

RESULTS

Prior to implementation of the respiratory service, increases in COPD EAs over time were evident in NW. Adjusting for changes in COPD EAs in NE + S, an additional reduction of -0.04 (-0.03, -0.05) per 1,000 population per month was observed in NW following the phase-in, so that by March 2015, the predicted reduction due to the respiratory service was -0.85 COPD EAs per 1,000 population, a relative reduction of 34.3%. No significant changes in admissions with COPD as a secondary diagnosis (COPD5 EAs) were observed, suggesting that the intervention had no impact on these.

CONCLUSIONS

The community respiratory service was associated with a significant reduction in the rate of COPD EAs among older people and no change in COPD5 EAs.

Who cares when you close down? The effects of primary care practice closures on patients

This paper investigates the consequences that patients face when their regular general practitioner (GP) closes down her practice, typically due to retirement. We estimate the causal impact of closures on patients' utilization patterns, healthcare expenditures, hospitalizations, mortality, and health plan choices. Employing a difference-in-difference framework, we find that patients who experience a discontinuity of care persistently adjust their ambulatory utilization pattern by shifting visits away from GPs (-12%) toward specialists (+11%) and hospital outpatient facilities (+6%). In contrast, we find no evidence on adverse health effects as measured by hospitalizations and mortality. The impact on utilization is heterogeneous along several dimensions. In particular, we find geographic disparities between regions with high and low availability of primary care. We also observe that patients with chronic conditions substitute more strongly toward other providers. Our results have potential implications for health policy in at least two dimensions: first, practice closures lead to more fragmented care which may entail inefficiencies, and second, closures deteriorate access to primary care in regions with low physician density.

Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study

Background

Primary health care is subject to regional variation, which may be due to unequal and inefficient distribution of services. One key measure of such variation are potentially avoidable hospitalisations, i.e., hospitalisations for conditions that could have been dealt with in situ by sufficient primary health care provision. Particularly, potentially avoidable hospitalisations for ambulatory care-sensitive conditions (ACSCs) are a substantial and growing burden for health care systems that require targeting in health care policy.

Aims

Using data from the Swiss Federal Statistical Office (SFSO) from 2017, we applied small area analysis to visualize regional variation to comprehensively map potentially avoidable hospitalisations for five ACSCs from Swiss nursing homes, home care organisations and the general population.

Methods

This retrospective observational study used data on all Swiss hospitalisations in 2017 to assess regional variations of potentially avoidable hospitalisations for angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications and hypertension. We used small areas, utilisation-based hospital service areas (HSAs), and administrative districts (Cantons) as geographic zones. The outcomes of interest were age and sex standardised rates of potentially avoidable hospitalisations for ACSCs in adults (> 15 years). Our inferential analyses used linear mixed models with Gaussian distribution.

Results

We identified 46,479 hospitalisations for ACSC, or 4.3% of all hospitalisations. Most of these occurred in the elderly population for congestive heart failure and COPD. The median rate of potentially avoidable hospitalisation for ACSC was 527 (IQR 432–620) per 100.000 inhabitants. We found substantial regional variation for HSAs and administrative districts as well as disease-specific regional patterns.

Conclusions

Differences in continuity of care might be key drivers for regional variation of potentially avoidable hospitalisations for ACSCs. These results provide a new perspective on the functioning of primary care structures in Switzerland and call for novel approaches in effective primary care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06876-5.

Avoidable Hospitalization for Heart Failure Among a Cohort of 18- to 64-Year-Old Italian Citizens and Immigrants: Results From the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND

Heart failure (HF) represents a severe public health burden. In Europe, differences in hospitalizations for HF have been found between immigrants and native individuals, with inconsistent results. Immigrants face many barriers in their access to health services, and their needs may be poorly met. We aimed to compare the rates of avoidable hospitalization for HF among immigrants and native individuals in Italy.

METHODS

All 18- to 64-year-old residents of Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome between January 1, 2001 and December 31, 2013 were included in this multicenter open-cohort study. Immigrants from high migratory pressure countries (divided by area of origin) were compared with Italian citizens. Age-, sex-, and calendar year-adjusted hospitalization rate ratios and the 95% CIs of avoidable hospitalization for HF by citizenship were estimated using negative binomial regression models. The hospitalization rate ratios were summarized using a random effects meta-analysis. Additionally, we tested the contribution of socioeconomic status to these disparities.

RESULTS

Of the 4 470 702 subjects included, 15.8% were immigrants from high migratory pressure countries. Overall, immigrants showed a nonsignificant increased risk of avoidable hospitalization for HF (hospitalization rate ratio, 1.26 [95% CI, 0.97-1.68]). Risks were higher for immigrants from Sub-Saharan Africa and for males from Northern Africa and Central-Eastern Europe than for their Italian citizen counterparts. Risks were attenuated adjusting for socioeconomic status, although they remained consistent with nonadjusted results.

CONCLUSIONS

Adult immigrants from different geographic macroareas had higher risks of avoidable hospitalization for HF than Italian citizens. Possible explanations might be higher risk factors among immigrants and reduced access to primary health care services.

Space-time clustering and temporal trends of hospitalizations due to pulmonary tuberculosis: potential strategy for assessing health care policies

BACKGROUND

Tuberculosis (TB) causes pressure on healthcare resources, especially in terms of hospital admissions, despite being considered an ambulatory care-sensitive condition for which timely and effective care in ambulatory setting could prevent the need for hospitalization. Our objectives were to describe the spatial and temporal variation in pulmonary tuberculosis (PTB) hospitalizations, identify critical geographic areas at municipality level and characterize clusters of PTB hospitalizations to help the development of tailored disease management strategies that could improve TB control.

METHODS

Ecologic study using sociodemographic, geographical and clinical information of PTB hospitalization cases from continental Portuguese public hospitals, between 2002 and 2016. Descriptive statistics, spatiotemporal cluster analysis and temporal trends were conducted.

RESULTS

The space-time analysis identified five clusters of higher rates of PTB hospitalizations (2002-16), including the two major cities in the country (Lisboa and Porto). Globally, we observed a -7.2% mean annual percentage change in rate with only one of the identified clusters (out of six) with a positive trend (+4.34%). In the more recent period (2011-16) was obtained a mean annual percentage change in rate of -8.12% with only one cluster identified with an increase trend (+9.53%).

CONCLUSIONS

Our results show that space-time clustering and temporal trends analysis can be an invaluable resource to monitor the dynamic of the disease and contribute to the design of more effective, focused interventions. Interventions such as enhancing the detection of active and latent infection, improving monitoring and evaluation of treatment outcomes or adjusting the network of healthcare providers should be tailored to the specific needs of the critical areas identified.

Associations of GP practice characteristics with the rate of ambulatory care sensitive conditions in people living with dementia in England: an ecological analysis of routine data

BACKGROUND

Hospital admissions for Ambulatory Care Sensitive Conditions (ACSCs) are potentially avoidable. Dementia is one of the leading chronic conditions in terms of variability in ACSC admissions by general practice, as well as accounting for around a third of UK emergency admissions.

METHODS

Using Bayesian multilevel linear regression models, we examined the ecological association of organizational characteristics of general practices (ACSC n=7076, non-ACSC n=7046 units) and Clinical Commissioning Groups (CCG n=212 units) in relation to ACSC and non-ACSC admissions for people with dementia in England.

RESULTS

The rate of hospital admissions are variable between GP practices, with deprivation and being admitted from home as risk factors for admission for ACSC and non-ACSC admissions. The budget allocated by the CCG to mental health shows diverging effects for ACSC versus non-ACSC admissions, so it is likely there is some geographic variation.

CONCLUSIONS

A variety of factors that could explain avoidable admissions for PWD at the practice level were examined; most were equally predictive for avoidable and non-avoidable admissions. However, a high amount of variation found at the practice level, in conjunction with the diverging effects of the CCG mental health budget, implies that guidance may be applied inconsistently, or local services may have differences in referral criteria. This indicates there is potential scope for improvement.

Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study

AIMS/INTRODUCTION

Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data.

MATERIALS AND METHODS

We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome.

RESULTS

We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis.

CONCLUSIONS

Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty.

The impact of the dependent care provision on individuals with spina bifida transitioning to adulthood

INTRODUCTION

Under the Affordable Care Act, the Dependent Care Provision (DCP) was enacted in 2010 and expanded healthcare coverage for millions of young adults ages 19-25 by allowing them to stay on their parents' insurance until age 26. It is unknown whether the DCP has impacted young adults with SB who are at risk for lapses in insurance coverage as they transition into adult care.

OBJECTIVE

Our aim was to determine the impact of the DCP on access to care (insurance status) and healthcare-quality (hospital admissions for potentially preventable conditions).

METHODS

Using the National Inpatient Sample (an all-payor national dataset of hospital admissions), we analyzed pre/post DCP changes for admissions of SB patients ages 19-25. Our outcomes of interest were rates of insurance coverage and proportion of admissions due to potentially preventable conditions (UTI, pyelonephritis, skin conditions, osteomyelitis, sepsis, and pneumonia). Analysis included a difference-in-differences logistic regression model which compared the pre/post DCP difference (2006-s quarter of 2010 vs. 2011-2013) in patients ages 19-25 to the difference in patients ages 26-32 who were ineligible for the DCP policy.

RESULTS

For admissions of SB patients ages 19-25, the DCP was not associated with improved insurance status compared to admissions ages 26-32 (0% vs. -0.4%, p = 0.10) and rates of private insurance decreased in both age groups, but more so in ages 26-32 (-2.0% vs. -3.9%, p < 0.001). Private insurance rates increased for admissions of white patients ages 19-25 but not for black and Hispanic groups. An increase in overall insurance status was also seen in young adults from high-income zip codes. Admissions for potentially preventable conditions increased in both age groups by a similar degree (+2.6% vs. +2.5%, p = 0.82).

DISCUSSION

Under the Affordable Care Act, the DCP failed to improve rates of private insurance or decrease rates of noninsurance for admissions of young adults with SB. Certain race and socioeconomic groups benefited more from this national healthcare policy. Meanwhile, admissions for potentially preventable conditions are common in spina bifida patients, and increased over the study period, suggesting a need for further investigation into optimizing the delivery of healthcare to this complex patient population.

CONCLUSION

The DCP did not result in improved overall insurance rates or in improved rates of private insurance for admissions of SB patients 18-25 years old.

INDEED-Utilization and Cross-Sectoral Patterns of Care for Patients Admitted to Emergency Departments in Germany: Rationale and Study Design

Introduction: The crowding of emergency departments (ED) has been a growing problem for years, putting the care of critically ill patients increasingly at risk. The INDEED project's overall aim is to get a better understanding of ED utilization and to evaluate corresponding primary health care use patterns before and after an ED visit while driving forward processes and methods of cross-sectoral data merging. We aim to identify adequate utilization of EDs and potentially avoidable patient contacts as well as subgroups and clusters of patients with similar care profiles.

Methods: INDEED is a joint endeavor bringing together research institutions and hospitals with EDs in Germany. It is headed by the Charité–Universitätsmedizin Berlin, collaborating with Otto von Guericke University Magdeburg, Technische Universität Berlin, the Central Research Institute of Ambulatory/Outpatient Health Care in Germany (Zi), and the AOK Research Institute as part of the Federal Association of AOK, as well as experts in the technological, legal, and regulatory aspects of medical research (TMF). The Institute for Information Technology (OFFIS) was involved as the trusted third party of the project. INDEED is a retrospective study of approximately 400,000 adult patients with statutory health insurance who visited the ED of one of 16 participating hospitals in 2016. The routine hospital data contain information about treatment in the ED and, if applicable, about the subsequent hospital stay. After merging the patients' hospital data from 2016 with their outpatient billing data from 2 years before to 1 year after the ED visit (years 2014–2017), a harmonized dataset will be generated for data analyses. Due to the complex data protection challenges involved, first results will be available in 2021.

Discussion: INDEED will provide knowledge on extracting and harmonizing large scale data from varying routine ED and hospital information systems in Germany. Merging these data with the corresponding outpatient care data of patients offers the opportunity to characterize the patient's treatment in outpatient care before and after ED use. With this knowledge, appropriate interventions may be developed to ensure adequate patient care and to avoid adverse events such as ED crowding.

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

OBJECTIVES

England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.

DESIGN

Historical cohort study.

SETTING

A total of 330 English primary care practices, 2010-2017, using UK Clinical Practice Research Datalink.

PARTICIPANTS

A total of 84,441 adults with type 2 diabetes.

MAIN OUTCOME MEASURES

The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.

RESULTS

There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89-0.92; p < 0.001 and 0.87; 95% CI 0.86-0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96-0.99; p = 0.001). Strong associations were found between completing 7-9 (vs. either 4-6 or 0-3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7-9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.

CONCLUSIONS

Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.

Potentially preventable hospitalisations for physical health conditions in community mental health service users: a population-wide linkage study

AIMS

Mental health (MH) service users have increased prevalence of chronic physical conditions such as cardio-respiratory diseases and diabetes. Potentially Preventable Hospitalisations (PPH) for physical health conditions are an indicator of health service access, integration and effectiveness, and are elevated in long term studies of people with MH conditions. We aimed to examine whether PPH rates were elevated in MH service users over a 12-month follow-up period more suitable for routine health indicator reporting. We also examined whether MH service users had increased PPH rates at a younger age, potentially reflecting the younger onset of chronic physical conditions.

METHODS

A population-wide data linkage in New South Wales (NSW), Australia, population 7.8 million. PPH rates in 178 009 people using community MH services in 2016-2017 were compared to population rates. Primary outcomes were crude and age- and disadvantage-standardised annual PPH episode rate (episodes per 100 000 population), PPH day rate (hospital days per 100 000) and adjusted incidence rate ratios (AIRR).

RESULTS

MH service users had higher rates of PPH admission (AIRR 3.6, 95% CI 3.5-3.6) and a larger number of hospital days (AIRR 5.2, 95% CI 5.2-5.3) than other NSW residents due to increased likelihood of admission, more admissions per person and longer length of stay. Increases were greatest for vaccine-preventable conditions (AIRR 4.7, 95% CI 4.5-5.0), and chronic conditions (AIRR 3.7, 95% CI 3.6-3.7). The highest number of admissions and relative risks were for respiratory and metabolic conditions, including chronic obstructive airways disease (AIRR 5.8, 95% CI 5.5-6.0) and diabetic complications (AIRR 5.4, 95% CI 5.1-5.8). One-quarter of excess potentially preventable bed days in MH service users were due to vaccine-related conditions, including vaccine-preventable respiratory illness. Age-related increases in risk occurred earlier in MH service users, particularly for chronic and vaccine-preventable conditions. PPH rates in MH service users aged 20-29 were similar to population rates of people aged 60 and over. These substantial differences were not explained by socio-economic disadvantage.

CONCLUSIONS

PPHs for physical health conditions are substantially increased in people with MH conditions. Short term (12-month) PPH rates may be a useful lead indicator of increased physical morbidity and less accessible, integrated or effective health care. High hospitalisation rates for vaccine-preventable respiratory infections and hepatitis underline the importance of vaccination in MH service users and suggests potential benefits of prioritising this group for COVID-19 vaccination.

A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

Background

An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support.

Objectives

Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted.

Design

A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect.

Setting

Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7).

Participants

We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting.

Intervention

This ran from February to July 2018.

Data sources

Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed.

Results

The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated.

Limitations

The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent.

Conclusion

A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies.

Future work

Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses.

Trial registration

Current Controlled Trials ISRCTN74109734 and ISRCTN86811077.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Association between Adherence to Recommended Care and Outcomes for Adult Survivors of Sepsis

Rationale: Postsepsis care recommendations target specific deficits experienced by sepsis survivors in elements such as optimization of medications, screening for functional impairments, monitoring for common and preventable causes of health deterioration, and consideration of palliative care. However, few data are available regarding the application of these elements in clinical practice.Objectives: To quantify the delivery of postsepsis care for patients discharged after hospital admission for sepsis and evaluate the association between receipt of postsepsis care elements and reduced mortality and hospital readmission within 90 days.Methods: We conducted a retrospective chart review of a random sample of patients who were discharged alive after an admission for sepsis (identified from International Classification of Diseases, 10th Revision discharge codes) at 10 hospitals during 2017. We used a structured chart abstraction to determine whether four elements of postsepsis care were provided within 90 days of hospital discharge, per expert recommendations. We used multivariable logistic regression to evaluate the association between receipt of care elements and 90-day hospital readmission and mortality, adjusted for age, comorbidity, length of stay, and discharge disposition.Results: Among 189 sepsis survivors, 117 (62%) had medications optimized, 123 (65%) had screening for functional or mental health impairments, 86 (46%) were monitored for common and preventable causes of health deterioration, and 110 (58%) had care alignment processes documented (i.e., assessed for palliative care or goals of care). Only 20 (11%) received all four care elements within 90 days. Within 90 days of discharge, 66 (35%) patients were readmitted and 33 (17%) died (total patients readmitted or died, n = 82). Receipt of two (odds ratio [OR], 0.26; 95% confidence interval [95% CI], 0.10-0.69) or more (three OR, 0.28; 95% CI, 0.11-0.72; four OR, 0.12; 95% CI, 0.03-0.50) care elements was associated with lower odds of 90-day readmission or 90-day mortality compared with zero or one element documented. Optimization of medications (no medication errors vs. one or more errors; OR, 0.44; 95% CI, 0.21-0.92), documented functional or mental health assessments (physical function plus swallowing/mental health assessments vs. no assessments; OR, 0.14; 95% CI, 0.05-0.40), and documented goals of care or palliative care screening (OR, 0.52; 95% CI, 0.25-1.05; not statistically significant) were associated with lower odds of 90-day readmission or 90-day mortality.Conclusions: In this retrospective cohort study of data from a single health system, we found variable delivery of recommended postsepsis care elements that were associated with reduced morbidity and mortality after hospitalization for sepsis. Implementation strategies to efficiently overcome barriers to adopting recommended postsepsis care may help improve outcomes for sepsis survivors.

Development of the PriCARE classification for potentially preventable emergency department visits by ambulance: a RAND/UCLA modified Delphi study protocol

INTRODUCTION

Ontario ambulances are restricted from patient transportation to sub-acute levels of care when these facilities may be more suitable than emergency departments for non-emergent conditions. There is no known patient classification specifically constructed to inform ED diversion protocols and guidance for sub-acute centre transportation for primary care-like patient conditions.

OBJECTIVE

To construct a novel patient classification of potentially preventable emergency department visits following transport by ambulance, and analyse patient-level characteristic associations with this classification based in Ontario secondary data.

METHODS AND ANALYSIS

The Primary Care-like Ambulance transports following Response for 911-Emergencies (PriCARE) patient classification will be constructed using a two-phase RAND/UCLA modified Delphi design. All experts included are physicians with relevant experience in emergency and/or primary care in Ontario. The first phase of the study will determine consensus of the expert committee on which ED interventions performed on patients with non-emergent acuities could be conducted in sub-acute healthcare centres. The second phase will assess consensus of which patient, hospital and acuity factors are most appropriate to be incorporated into a PriCARE classification. We will also investigate secondary outcomes on consensus of which ED interventions could be transferred to a paramedic context given an expanded scope of practice and patient-level characteristics of PriCARE classified individuals.

ETHICS AND DISSEMINATION

This study received a research ethics board exemption waiver from the Hamilton Integrated Research Ethics Board; review reference 2020-11451-GRA. Results will be submitted for publication in a peer-reviewed journal and presented at relevant conferences. The results will be shared with Ontario paramedic services and governing institutions. This study will be used to inform patient classification protocols and clinical decision tools for ambulances to transport to sub-acute healthcare centres.

TRIAL REGISTRATION NUMBER

ISRCTN22901977.