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

Calculating hospital length of stay using the Hospital Episode Statistics; a comparison of methodologies

BACKGROUND

Accurate calculation of hospital length of stay (LOS) from the English Hospital Episode Statistics (HES) is important for a wide range of audit and research purposes. The two methodologies which are commonly used to achieve this differ in their accuracy and complexity. We compare these methods and make recommendations on when each is most appropriate.

METHODS

We calculated LOS using continuous inpatient spells (CIPS), which link care spanning across multiple hospitals, and spells, which do not, for six conditions with short (dyspepsia or other stomach function, ENT infection), medium (dehydration and gastroenteritis, perforated or bleeding ulcer), and long (stroke, fractured proximal femur) average LOS. We examined how inter-area comparisons (i.e. benchmarking) and temporal trends differed. We defined a classification system for spells and explored the causes of differences.

RESULTS

Stroke LOS was 16.5 days using CIPS but 24% (95% CI: 23, 24) lower, at 12.6 days, using spells. Smaller differences existed for shorter-LOS conditions including dehydration and gastroenteritis (4.5 vs. 4.2 days) and ENT infection (0.9 vs. 0.8 days). Typical patient pathways differed markedly between areas and have evolved over time. One area had the third shortest stroke LOS (out of 151) using spells but the fourth longest using CIPS. These issues were most profound for stroke and fractured proximal femur, as patients were frequently transferred to a separate hospital for rehabilitation, however important disparities also existed for conditions with simpler secondary care pathways (e.g. ENT infections, dehydration and gastroenteritis).

CONCLUSIONS

Spell-based LOS is widely used by researchers and national reporting organisations, including the Health and Social Care Information Centre, however it can substantially underestimate the time patients spend in hospital. A widespread shift to a CIPS methodology is required to improve the quality of LOS estimates and the robustness of research and benchmarking findings. This is vital when investigating clinical areas with typically long, complex patient pathways. Researchers should ensure that their LOS calculation methodology is fully described and explicitly acknowledge weaknesses when appropriate.

Hospital admissions for physical health conditions for people with intellectual disabilities: Systematic review

BACKGROUND

People with intellectual disabilities may have inequalities in hospital admissions compared with the general population. The present authors aimed to investigate admissions for physical health conditions in this population.

METHODS

The present authors conducted a systematic review, searching six databases using terms on intellectual disabilities and hospital admission. Papers were selected based on pre-defined inclusion/exclusion criteria, data extracted, tabulated and synthesized and quality assessed. PROSPERO registration number: CRD42015020575.

RESULTS

Seven of 29,613 papers were included. There were more admissions, and a different pattern of admissions (more medical and dental), for people with intellectual disabilities, but most studies did not take account of higher disease prevalence. Three papers considered admissions for ambulatory care-sensitive conditions, two of which accounted for disease prevalence (asthma, diabetes) and found higher admission rates for people with intellectual disabilities.

CONCLUSION

Admissions are common. Asthma and diabetes admission data suggest suboptimal primary health care for people with intellectual disabilities compared with the general population, but evidence is limited.

Association between expansion of primary healthcare and racial inequalities in mortality amenable to primary care in Brazil: A national longitudinal analysis

BACKGROUND

Universal health coverage (UHC) can play an important role in achieving Sustainable Development Goal (SDG) 10, which addresses reducing inequalities, but little supporting evidence is available from low- and middle-income countries. Brazil's Estratégia de Saúde da Família (ESF) (family health strategy) is a community-based primary healthcare (PHC) programme that has been expanding since the 1990s and is the main platform for delivering UHC in the country. We evaluated whether expansion of the ESF was associated with differential reductions in mortality amenable to PHC between racial groups.

METHODS AND FINDINGS

Municipality-level longitudinal fixed-effects panel regressions were used to examine associations between ESF coverage and mortality from ambulatory-care-sensitive conditions (ACSCs) in black/pardo (mixed race) and white individuals over the period 2000-2013. Models were adjusted for socio-economic development and wider health system variables. Over the period 2000-2013, there were 281,877 and 318,030 ACSC deaths (after age standardisation) in the black/pardo and white groups, respectively, in the 1,622 municipalities studied. Age-standardised ACSC mortality fell from 93.3 to 57.9 per 100,000 population in the black/pardo group and from 75.7 to 49.2 per 100,000 population in the white group. ESF expansion (from 0% to 100%) was associated with a 15.4% (rate ratio [RR]: 0.846; 95% CI: 0.796-0.899) reduction in ACSC mortality in the black/pardo group compared with a 6.8% (RR: 0.932; 95% CI: 0.892-0.974) reduction in the white group (coefficients significantly different, p = 0.012). These differential benefits were driven by greater reductions in mortality from infectious diseases, nutritional deficiencies and anaemia, diabetes, and cardiovascular disease in the black/pardo group. Although the analysis is ecological, sensitivity analyses suggest that over 30% of black/pardo deaths would have to be incorrectly coded for the results to be invalid. This study is limited by the use of municipal-aggregate data, which precludes individual-level inference. Omitted variable bias, where factors associated with ESF expansion are also associated with changes in mortality rates, may have influenced our findings, although sensitivity analyses show the robustness of the findings to pre-ESF trends and the inclusion of other municipal-level factors that could be associated with coverage.

CONCLUSIONS

PHC expansion is associated with reductions in racial group inequalities in mortality in Brazil. These findings highlight the importance of investment in PHC to achieve the SDGs aimed at improving health and reducing inequalities.

Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data

Background

Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system.

Methods

Using routinely collected health billing records for 2005–2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply–side variables, and PHC use.

Findings

Over the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow–up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services.

Interpretation

Our findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.

Impact of Disease Prevalence Adjustment on Hospitalization Rates for Chronic Ambulatory Care-Sensitive Conditions in Germany

OBJECTIVES

To explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons.

DATA SOURCES/STUDY SETTING

County-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used.

STUDY DESIGN

A retrospective cross-sectional study using in- and outpatient secondary data was performed.

DATA COLLECTION

Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care.

PRINCIPAL FINDINGS

Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment.

CONCLUSIONS

Unadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.

Evaluation of Ambulatory Geriatric Rehabilitation (EAGER): study protocol of a matched cohort study based on claims data

BACKGROUND

Ambulatory geriatric rehabilitation (AGR) is a community based outpatient intervention which aims to improve physical function, maintain independent living of geriatric patients, avoiding hospitalisation and institutionalisation. It should therefore reduce health care costs. The objective of our study is to evaluate the effectiveness of AGR for frail elderly patients insured by the statutory health insurance AOK Nordost compared to care as usual. Outcome variables are progression to higher nursing care levels, admission to nursing home, incident fractures, hospital admission, ambulatory care sensitive hospital admissions, days spent in hospital, and health care costs.

METHODS

This matched cohort study aims to estimate average treatment effects of AGR. For this purpose we will compare patients receiving AGR with matched patients receiving care as usual. Patients in the intervention group were treated between the years 2009 and 2013 from three centres in Mecklenburg-Vorpommern, Germany. Matching will be conducted using propensity score techniques. Claims data will be provided by the statutory health insurance AOK Nordost. The primary outcomes are the progression of nursing care levels, incident fractures, and admission to nursing home. Secondary outcomes are total and ambulatory care sensitive hospital admissions, and health care costs from the statutory health insurance perspective. Data will be analysed using appropriate regression models.

DISCUSSION

This study aims to quantify the effectiveness of AGR. Results will be important for providers of AGR, policy makers and stakeholders to make informed decisions on whether to continue, modify or extend AGR.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) S00008926 , registered 29.07.2015.

Does Quality Affect Patients' Choice of Doctor? Evidence from England

Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%.

Factors associated with hospitalisations in chronic conditions deemed avoidable: ecological study in the Spanish healthcare system

OBJECTIVES

Potentially avoidable hospitalisations have been used as a proxy for primary care quality. We aimed to analyse the ecological association between contextual and systemic factors featured in the Spanish healthcare system and the variation in potentially avoidable hospitalisations for a number of chronic conditions.

METHODS

A cross-section ecological study based on the linkage of administrative data sources from virtually all healthcare areas (n=202) and autonomous communities (n=16) composing the Spanish National Health System was performed. Potentially avoidable hospitalisations in chronic conditions were defined using the Spanish validation of the Agency for Health Research and Quality (AHRQ) preventable quality indicators. Using 2012 data, the ecological association between potentially avoidable hospitalisations and factors featuring healthcare areas and autonomous communities was tested using multilevel negative binomial regression.

RESULTS

In 2012, 151 468 admissions were flagged as potentially avoidable in Spain. After adjusting for differences in age, sex and burden of disease, the only variable associated with the outcome was hospitalisation intensity for any cause in previous years (incidence risk ratio 1.19 (95% CI 1.13 to 1.26)). The autonomous community of residence explained a negligible part of the residual unexplained variation (variance 0.01 (SE 0.008)). Primary care supply and activity did not show any association.

CONCLUSIONS

The findings suggest that the variation in potentially avoidable hospitalisations in chronic conditions at the healthcare area level is a reflection of how intensively hospitals are used in a healthcare area for any cause, rather than of primary care characteristics. Whether other non-studied features at the healthcare area level or primary care level could explain the observed variation remains uncertain.

Living In A Country With A Strong Primary Care System Is Beneficial To People With Chronic Conditions

In light of the growing pressure that multiple chronic diseases place on health care systems, we investigated whether strong primary care was associated with improved health outcomes for the chronically ill. We did this by combining country- and individual-level data for the twenty-seven countries of the European Union, focusing on people's self-rated health status and whether or not they had severe limitations or untreated conditions. We found that people with chronic conditions were more likely to be in good or very good health in countries that had a stronger primary care structure and better coordination of care. People with more than two chronic conditions benefited most: Their self-rated health was higher if they lived in countries with a stronger primary care structure, better continuity of care, and a more comprehensive package of primary care services. In general, while having access to a strong primary care system mattered for people with chronic conditions, the degree to which it mattered differed across specific subgroups (for example, people with primary care-sensitive conditions) and primary care dimensions. Primary care reforms, therefore, should be person centered, addressing the needs of subgroups of patients while also finding a balance between structure and service delivery.

Impact of the Affordable Care Act Medicaid expansion on emergency department high utilizers with ambulatory care sensitive conditions: A cross-sectional study

OBJECTIVES

The effect of the Affordable Care Act on emergency department (ED) high utilizers has not yet been thoroughly studied. We sought to determine the impact of changes in insurance eligibility following the 2014 Medicaid expansion on ED utilization for ambulatory care sensitive conditions (ACSC) by high ED utilizers in an urban safety net hospital.

METHODS

High utilizers were defined as patients with ≥4 visits in the 6months before their most recent visit in the study period (July-December before and after Maryland's Medicaid expansion in January 2014). A differences-in-differences approach using logistic regression was used to investigate if differences between high and low utilizer cohorts changed from before and after the expansion.

RESULTS

During the study period, 726 (4.1%) out of 17,795 unique patients in 2013 and 380 (2.4%) of 16,458 during the same period in 2014 were high utilizers (p-value <0.001). ACSC-associated visit predicted being a high utilizer in 2013 (OR 1.66 (95% CI [1.37, 2.01])) and 2014 (OR 1.65 (95% CI [1.27, 2.15])) but this was not different between years (OR ratio 0.99, 95% CI [0.72, 1.38], p-value 0.97).

CONCLUSION

Although the proportion of high utilizers decreased significantly after Maryland's Medicaid expansion, ACSC-associated ED visits by high ED utilizers were unaffected.

Racial and Ethnic Disparities in Preventable Hospitalizations for Chronic Disease: Prevalence and Risk Factors

BACKGROUND

Hospitalizations due to ambulatory care sensitive conditions (ACSCs) result in high morbidity and economic burden on the American healthcare system. Admissions due to chronic ACSCs, in particular, cost the American healthcare system over 30 billion dollars annually.

OBJECTIVES AND METHODS

This paper presents the current research on racial and ethnic disparities in the burden of hospitalizations due to chronic ACSCs. For this narrative review, we evaluated over 800 abstracts from MEDLINE and Google Scholar and cited 62 articles.

RESULTS

Since 1998, racial and ethnic disparities in hospitalizations from chronic ACSCs have increased resulting in over 430,000 excess hospitalizations among non-Hispanic Blacks compared to non-Hispanic Whites.

CONCLUSIONS

Racial disparities in chronic ACSCs hospitalizations are pervasive in the USA. There is need for more research on the pathways through which an individual's race modifies the risk for hospitalizations due to chronic ACSCs.

Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities: an analysis of routine data from England

Objectives To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care. Methods We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios. Results There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (<2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually. Conclusions Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions.

Mandatory Statewide Medicaid Managed Care in Florida and Hospitalizations for Ambulatory Care Sensitive Conditions

OBJECTIVE

To investigate the impact of implementation of the Statewide Medicaid Managed Care (SMMC) program in Florida on access to and quality of primary care for Medicaid enrollees, measured by hospitalizations for ambulatory care sensitive conditions (ACSCs).

DATA SOURCES

We examine inpatient data obtained from the Agency for Health Care Administration for 285 hospitals in Florida from January 2010 to June 2015. The analysis includes 3,645,515 discharges for Florida residents between the ages 18 and 64 with a primary payer of Medicaid or private insurance.

STUDY DESIGN

We use a difference-in-differences approach, comparing the change in the incidence of ACSC-related inpatient visits among Medicaid patients before and after the implementation of SMMC, relative to the change among the privately insured.

PRINCIPAL FINDINGS

After implementation of SMMC, Medicaid patients experienced a 0.35 percentage point slower growth in overall ACSC-related inpatient visits, and a 0.21 percentage point slower growth in chronic ACSC-related inpatient visits. The effects were significant in counties with above median Medicaid managed care penetration rates.

CONCLUSIONS

Implementing mandatory managed care in Medicaid in Florida leads to slower growth in inpatient visits for conditions that can potentially be prevented with improved access to outpatient care.

Are some areas more equal than others? Socioeconomic inequality in potentially avoidable emergency hospital admissions within English local authority areas

Objectives Reducing health inequalities is an explicit goal of England's health system. Our aim was to compare the performance of English local administrative areas in reducing socioeconomic inequality in emergency hospital admissions for ambulatory care sensitive chronic conditions. Methods We used local authority area as a stable proxy for health and long-term care administrative geography between 2004/5 and 2011/12. We linked inpatient hospital activity, deprivation, primary care, and population data to small area neighbourhoods (typical population 1500) within administrative areas (typical population 250,000). We measured absolute inequality gradients nationally and within each administrative area using neighbourhood-level linear models of the relationship between national deprivation and age-sex-adjusted emergency admission rates. We assessed local equity performance by comparing local inequality against national inequality to identify areas significantly more or less equal than expected; evaluated stability over time; and identified where equity performance was steadily improving or worsening. We then examined associations between change in socioeconomic inequalities and change in within-area deprivation (gentrification). Finally, we used administrative area-level random and fixed effects models to examine the contribution of primary care to inequalities in admissions. Results Data on 316 administrative areas were included in the analysis. Local inequalities were fairly stable between consecutive years, but 32 areas (10%) showed steadily improving or worsening equity. In the 21 improving areas, the gap between most and least deprived fell by 3.9 admissions per 1000 (six times the fall nationally) between 2004/5 and 2011/12, while in the 11 areas worsening, the gap widened by 2.4. There was no indication that measured improvements in local equity were an artefact of gentrification or that changes in primary care supply or quality contributed to changes in inequality. Conclusions Local equity performance in reducing inequality in emergency admissions varies both geographically and over time. Identifying this variation could provide insights into which local delivery strategies are most effective in reducing such inequalities.

Opportunities for primary care to reduce hospital admissions: a cross-sectional study of geographical variation

BACKGROUND

Reducing unplanned hospital admissions is a key priority within the UK. Substantial interpractice variation in admission rates for ambulatory care sensitive conditions (ACSC) suggests that decreases might be possible.

AIM

To identify the clinical areas and patient subgroups where the greatest opportunities exist for GPs to improve ACSC care.

DESIGN AND SETTING

Cross-sectional study using routine hospital data from patients registered at 8123 English GP practices during 2011 and 2012.

METHOD

The authors used random effects Poisson models to estimate interpractice variation after adjusting for several drivers of healthcare need and availability of local hospital services. Interpractice variation was contrasted across patient subgroups based on age.

RESULTS

There were 1.8 million hospital admissions. Overall, high-utilisation practices had ACSC admission rates that were 55% (95% CI = 53 to 56) greater than low-utilisation practices. Differences of 67% (95% CI = 65 to 69) were found for chronic ACSCs, which was much larger than the 51% (95% CI = 49 to 52) difference exhibited by acute presentations. At least two-fold differences were found for 15 (54%) ACSCs, although large interpractice variations were not ubiquitous. Admission rates were consistently more variable among younger-than-average patients. The most variable conditions tended to disproportionately affect deprived patients.

CONCLUSION

Substantial interpractice variation suggests that current efforts to standardise primary care have had a limited effect on unplanned hospital admissions. GPs and healthcare commissioners should ensure they are offering best practice care for the most variable clinical areas and patient subgroups identified in the study, particularly in adults aged <70 years with chronic conditions.

Should all acutely ill children in primary care be tested with point-of-care CRP: a cluster randomised trial

BACKGROUND

Point-of-care blood C-reactive protein (CRP) testing has diagnostic value in helping clinicians rule out the possibility of serious infection. We investigated whether it should be offered to all acutely ill children in primary care or restricted to those identified as at risk on clinical assessment.

METHODS

Cluster randomised controlled trial involving acutely ill children presenting to 133 general practitioners (GPs) at 78 GP practices in Belgium. Practices were randomised to undertake point-of-care CRP testing in all children (1730 episodes) or restricted to children identified as at clinical risk (1417 episodes). Clinical risk was assessed by a validated clinical decision rule (presence of one of breathlessness, temperature ≥ 40 °C, diarrhoea and age 12-30 months, or clinician concern). The main trial outcome was hospital admission with serious infection within 5 days. No specific guidance was given to GPs on interpreting CRP levels but diagnostic performance is reported at 5, 20, 80 and 200 mg/L.

RESULTS

Restricting CRP testing to those identified as at clinical risk substantially reduced the number of children tested by 79.9 % (95 % CI, 77.8-82.0 %). There was no significant difference between arms in the number of children with serious infection who were referred to hospital immediately (0.16 % vs. 0.14 %, P = 0.88). Only one child with a CRP < 5 mg/L had an illness requiring admission (a child with viral gastroenteritis admitted for rehydration). However, of the 80 children referred to hospital to rule out serious infection, 24 (30.7 %, 95 % CI, 19.6-45.6 %) had a CRP < 5 mg/L.

CONCLUSIONS

CRP testing should be restricted to children at higher risk after clinical assessment. A CRP < 5 mg/L rules out serious infection and could be used by GPs to avoid unnecessary hospital referrals.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02024282 (registered on 14^th September 2012).

Potentially avoidable and ambulatory care sensitive hospitalisations among forced migrants: a protocol for a systematic review and meta-analysis

INTRODUCTION

There is an increasing number of forced migrants globally, including refugees, asylum seekers, internally displaced persons and undocumented migrants. According to international law, forced migrants should enjoy access to health services free of discrimination equivalent to the host population, but they face barriers to healthcare worldwide. This may lead to a delay in care and result in preventable hospital treatment, referred to as potentially preventable hospitalisation (PPH) or ambulatory care sensitive hospitalisation (ACSH). There is as yet no overview of the prevalence of PPH in different countries and groups of forced migrants, and it is unknown whether the concept has been used among these migrant groups. We aim to systematically review the evidence (1) on the prevalence of PPH among forced migrants and (2) on differences in the prevalence of PPH between forced migrants and the general host population.

METHODS AND ANALYSIS

A systematic review will be conducted searching databases (PubMed/MEDLINE, Web of Science/Knowledge, Cochrane Library, CINAHL, Google Scholar) and the internet (Google).

INCLUSION CRITERIA

observational studies on forced migrants reporting PPH or ACSH with or without comparison groups published in the English or German language.

EXCLUSION CRITERIA

studies on general migrant groups or hospitalisations without clear reference to avoidability.

STUDY SELECTION

titles, abstracts and full texts will be screened in duplicate for eligibility. Data on the prevalence of PPH/ACSH among forced migrants, as well as any reported prevalence differences between host populations, will be systematically extracted. Quality appraisal will be performed using standardised checklists. The evidence will be synthesised in tabular form and by means of forest plots. A meta-analysis will be performed only among homogeneous studies (in terms of design and population).

ETHICS AND DISSEMINATION

Ethical clearance is not necessary (secondary research). The results will be disseminated via publication in open access journals, conferences and public media.

PROSPERO REGISTRATION NUMBER

CRD42016037081.

Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level

Background

Inequalities in health-care access and outcomes raise concerns about quality of care and justice, and the NHS has a statutory duty to consider reducing them.

Objectives

The objectives were to (1) develop indicators of socioeconomic inequality in health-care access and outcomes at different stages of the patient pathway; (2) develop methods for monitoring local NHS equity performance in tackling socioeconomic health-care inequalities; (3) track the evolution of socioeconomic health-care inequalities in the 2000s; and (4) develop ‘equity dashboards’ for communicating equity findings to decision-makers in a clear and concise format.

Design

Longitudinal whole-population study at the small-area level.

Setting

England from 2001/2 to 2011/12.

Participants

A total of 32,482 small-area neighbourhoods (lower-layer super output areas) of approximately 1500 people.

Main outcome measures

Slope index of inequality gaps between the most and least deprived neighbourhoods in England, adjusted for need or risk, for (1) patients per family doctor, (2) primary care quality, (3) inpatient hospital waiting time, (4) emergency hospitalisation for chronic ambulatory care-sensitive conditions, (5) repeat emergency hospitalisation in the same year, (6) dying in hospital, (7) mortality amenable to health care and (8) overall mortality.

Data sources

Practice-level workforce data from the general practice census (indicator 1), practice-level Quality and Outcomes Framework data (indicator 2), inpatient hospital data from Hospital Episode Statistics (indicators 3–6) and mortality data from the Office for National Statistics (indicators 6–8).

Results

Between 2004/5 and 2011/12, more deprived neighbourhoods gained larger absolute improvements on all indicators except waiting time, repeat hospitalisation and dying in hospital. In 2011/12, there was little measurable inequality in primary care supply and quality, but inequality was associated with 171,119 preventable hospitalisations and 41,123 deaths amenable to health care. In 2011/12, > 20% of Clinical Commissioning Groups performed statistically significantly better or worse than the England equity benchmark.

Limitations

General practitioner supply is a limited measure of primary care access, need in deprived neighbourhoods may be underestimated because of a lack of data on multimorbidity, and the quality and outcomes indicators capture only one aspect of primary care quality. Health-care outcomes are adjusted for age and sex but not for other risk factors that contribute to unequal health-care outcomes and may be outside the control of the NHS, so they overestimate the extent of inequality for which the NHS can reasonably be held responsible.

Conclusions

NHS actions can have a measurable impact on socioeconomic inequality in both health-care access and outcomes. Reducing inequality in health-care outcomes is more challenging than reducing inequality of access to health care. Local health-care equity monitoring against a national benchmark can be performed using any administrative geography comprising ≥ 100,000 people.

Future work

Exploration of quality improvement lessons from local areas performing well and badly on health-care equity, improved methods including better measures of need and risk and measures of health-care inequality over the life-course, and monitoring of other dimensions of equity. These indicators can also be used to evaluate the health-care equity impacts of interventions and make international health-care equity comparisons.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessing Impacts on Unplanned Hospitalisations of Care Quality and Access Using a Structural Equation Method: With a Case Study of Diabetes

Background: Enhanced quality of care and improved access are central to effective primary care management of long term conditions. However, research evidence is inconclusive in establishing a link between quality of primary care, or access, and adverse outcomes, such as unplanned hospitalisation. Methods: This paper proposes a structural equation model for quality and access as latent variables affecting adverse outcomes, such as unplanned hospitalisations. In a case study application, quality of care (QOC) is defined in relation to diabetes, and the aim is to assess impacts of care quality and access on unplanned hospital admissions for diabetes, while allowing also for socio-economic deprivation, diabetes morbidity, and supply effects. The study involves 90 general practitioner (GP) practices in two London Clinical Commissioning Groups, using clinical quality of care indicators, and patient survey data on perceived access. Results: As a single predictor, quality of care has a significant negative impact on emergency admissions, and this significant effect remains when socio-economic deprivation and morbidity are allowed. In a full structural equation model including access, the probability that QOC negatively impacts on unplanned admissions exceeds 0.9. Furthermore, poor access is linked to deprivation, diminished QOC, and larger list sizes. Conclusions: Using a Bayesian inference methodology, the evidence from the analysis is weighted towards negative impacts of higher primary care quality and improved access on unplanned admissions. The methodology of the paper is potentially applicable to other long term conditions, and relevant when care quality and access cannot be measured directly and are better regarded as latent variables.

Regional trends in avoidable hospitalisations due to complications among population with diabetes in Finland in 1996-2011: a register-based cohort study

OBJECTIVES

Diabetes requires continuous medical care including prevention of acute complications and risk reduction for long-term complications. Diabetic complications impose a substantial burden on public health and care delivery. We examined trends in regional differences in hospitalisations due to diabetes-related complications among the total diabetes population in Finland.

RESEARCH DESIGN

A longitudinal register-based cohort study 1996-2011 among a total population with diabetes in Finland.

PARTICIPANTS

All persons with diabetes identified from several administrative registers in Finland in 1964-2011 and alive on 1 January 1996.

OUTCOME MEASURES

We examined hospitalisations due to diabetes-related short-term and long-term complications, uncomplicated diabetes, myocardial infarction, stroke, lower extremity amputation and end-stage renal disease (ESRD). We calculated annual age-adjusted rates per 10 000 person years and the systematic component of variation. Multilevel models were used for studying time trends in regional variation.

RESULTS

There was a steep decline in complication-related hospitalisation rates during the study period. The decline was relatively small in ESRD (30%), whereas rates of hospitalisations for short-term and long-term complications as well as uncomplicated diabetes diminished by about 80%. The overall correlation between hospital district intercepts and slopes in time was -0.72 (p<0.001) among men and -0.99 (p<0.001) among women indicating diminishing variation. Diminishing variation was found in each of the complications studied. The variation was mainly distributed at the health centre level.

CONCLUSIONS

Our study suggests that the prevention of complications among persons with diabetes has improved in Finland between 1996 and 2011. The results further suggest that the prevention of complications has become more uniform throughout the country.

Pathways to potentially preventable hospitalizations for diabetes and heart failure: a qualitative analysis of patient perspectives

BACKGROUND

Potentially preventable hospitalizations (PPH) for heart failure (HF) and diabetes mellitus (DM) cost the United States over $14 billion annually. Studies about PPH typically lack patient perspectives, especially across diverse racial/ethnic groups with known PPH health disparities.

METHODS

English-speaking individuals with a HF or DM-related PPH (n = 90) at the largest hospital in Hawai'i completed an in-person interview, including open-ended questions on precipitating factors to their PPH. Using the framework approach, two independent coders identified patient-reported factors and pathways to their PPH.

RESULTS

Seventy-two percent of respondents were under 65 years, 30 % were female, 90 % had health insurance, and 66 % had previously been hospitalized for the same problem. Patients' stories identified immediate, precipitating, and underlying reasons for the admission. Underlying background factors were critical to understanding why patients had the acute problems necessitating their hospitalizations. Six, non-exclusive, underlying factors included: extreme social vulnerability (e.g., homeless, poverty, no social support, reported by 54 % of respondents); health system interaction issues (e.g., poor communication with providers, 44 %); limited health-related knowledge (42 %); behavioral health issues (e.g., substance abuse, mental illness, 36 %); denial of illness (27 %); and practical problems (e.g., too busy, 6 %). From these findings, we developed a model to understand an individual's pathways to a PPH through immediate, precipitating, and underlying factors, which could help identify potential intervention foci. We demonstrate the model's utility using five examples.

CONCLUSIONS

In a young, predominately insured population, factors well outside the traditional purview of the hospital, or even clinical medicine, critically influenced many PPH. Patient perspectives were vital to understanding this issue. Innovative partnerships and policies should address these issues, including linkages to social services and behavioral health.

The barriers to accessing primary care resulting in hospital presentation for exacerbation of asthma or chronic obstructive pulmonary disease in a large teaching hospital in London

Asthma and chronic obstructive pulmonary disease (COPD) account direct costs of £1 billion each per year in the United Kingdom (UK). A national review of asthma deaths found that a significant proportion of patients die without seeking medical assistance or before emergency medical care could be provided. This study aims to establish the pathway that patients undertake to access care in the lead up to an accident and emergency (A&E) attendance and/or inpatient admission. Patients attending A&E and/or following an inpatient admission due to an exacerbation of asthma or COPD were reviewed by a specialist respiratory pharmacist during weekday working hours. Over a one-year period, 920 (224 asthma and 696 COPD) presentations for exacerbation of asthma and COPD were reviewed. Although the majority of the patients were registered with a general practitioner (GP), less than 50% received medical attention from their GP and/or had an active intervention prior to presenting to hospital. These findings correlate with those found in the national review of asthma deaths. At a time of increasing demands on healthcare resources, these results pose the question of how we can better triage patients to appropriate care settings to minimise unscheduled care and improve patient outcomes.

Safer Prescribing--A Trial of Education, Informatics, and Financial Incentives

BACKGROUND

High-risk prescribing and preventable drug-related complications are common in primary care. We evaluated whether the rates of high-risk prescribing by primary care clinicians and the related clinical outcomes would be reduced by a complex intervention.

METHODS

In this cluster-randomized, stepped-wedge trial conducted in Tayside, Scotland, we randomly assigned participating primary care practices to various start dates for a 48-week intervention comprising professional education, informatics to facilitate review, and financial incentives for practices to review patients' charts to assess appropriateness. The primary outcome was patient-level exposure to any of nine measures of high-risk prescribing of nonsteroidal antiinflammatory drugs (NSAIDs) or selected antiplatelet agents (e.g., NSAID prescription in a patient with chronic kidney disease or coprescription of an NSAID and an oral anticoagulant without gastroprotection). Prespecified secondary outcomes included the incidence of related hospital admissions. Analyses were performed according to the intention-to-treat principle, with the use of mixed-effect models to account for clustering in the data.

RESULTS

A total of 34 practices underwent randomization, 33 of which completed the study. Data were analyzed for 33,334 patients at risk at one or more points in the preintervention period and for 33,060 at risk at one or more points in the intervention period. Targeted high-risk prescribing was significantly reduced, from a rate of 3.7% (1102 of 29,537 patients at risk) immediately before the intervention to 2.2% (674 of 30,187) at the end of the intervention (adjusted odds ratio, 0.63; 95% confidence interval [CI], 0.57 to 0.68; P<0.001). The rate of hospital admissions for gastrointestinal ulcer or bleeding was significantly reduced from the preintervention period to the intervention period (from 55.7 to 37.0 admissions per 10,000 person-years; rate ratio, 0.66; 95% CI, 0.51 to 0.86; P=0.002), as was the rate of admissions for heart failure (from 707.7 to 513.5 admissions per 10,000 person-years; rate ratio, 0.73; 95% CI, 0.56 to 0.95; P=0.02), but admissions for acute kidney injury were not (101.9 and 86.0 admissions per 10,000 person-years, respectively; rate ratio, 0.84; 95% CI, 0.68 to 1.09; P=0.19).

CONCLUSIONS

A complex intervention combining professional education, informatics, and financial incentives reduced the rate of high-risk prescribing of antiplatelet medications and NSAIDs and may have improved clinical outcomes. (Funded by the Scottish Government Chief Scientist Office; ClinicalTrials.gov number, NCT01425502.).

Incidence and Risk Factors Associated With Hospitalization for Variant Angina in Korea

This study aimed to determine the incidence and the risk factors of hospitalization for variant angina (VA) in Korean patients. Using the National Inpatient Sample (NIS) database, manufactured and released by the Health Insurance Review and Assessment Service (HIRA) in Korea, the incidence of hospitalization and rehospitalization for VA were calculated. The numbers of patients hospitalized for VA were estimated to be 14,362 in 2009, 17,492 in 2010, and 20,592 in 2011. The standardized incidence rates of hospitalization for VA were 31.4% in 2009, 36.5% in 2010, and 41.7% in 2011 (relative increase rate from 2009 to 2011, 33.0%, P for trend < 0.0001). VA patients predominantly belonged to the middle-age group between 40 and 69 years (75.5%), and there were 54.3% male. Based on the hospitalization episodes, the number of rehospitalization was calculated to be 879, 1141, and 1446 patients out of 1867, 2274, and 2677 patients from 2009, 2010, and 2011, respectively. The rates of rehospitalization for VA were 47.1% in 2009, 50.2% in 2010, and 54.0% in 2011 (P for trend < 0.0001). Age was an independent factor associated with rehospitalization for VA. Hospitalization for VA occurred most frequently in fall from 2009 to 2011. In conclusion, hospitalization rates for VA steadily increased from 2009 to 2011 in Korea, and about a half of VA patients was hospitalized more than once a year in 2009 to 2011. Proper health policy and patient education are warranted to control the high rate of hospitalization for VA.

[Pursuing the triple aim: evaluation of the integrated care system Gesundes Kinzigtal: population health, patient experience and cost-effectiveness]

BACKGROUND

The integrated care system Gesundes Kinzigtal (ICSGK), one of the most comprehensive population-based ICS in Germany, started its work nearly 9 years ago. The ICSGK is pursuing the Triple Aim: improving the health of the population, improving the individual's experience of care, and at the same time reducing the per capita costs of care.

OBJECTIVES

To evaluate the impact of the ICSGK on the Triple Aim.

MATERIALS AND METHODS

The ICSGK is being evaluated externally and internally via a mix of diverse quantitative and qualitative methods. This paper presents selected results for each Triple Aim dimension.

RESULTS AND CONCLUSIONS

Regarding population health, most of the quality indicators examined by the external scientific evaluation show positive development. For example, the prevalence of patients with fractures among all insurants with osteoporosis is presented. In 2011, this prevalence was approximately 26 % in the "Kinzigtal" population (aged ≥ 20 years old) in comparison to 33 % in the control group. As far as patient experience is concerned, to the question "Would you recommend becoming a member of Gesundes Kinzigtal to your friends or relatives?" 92.1 % of those questioned answered "Yes, for sure" or "Yes, probably." Twenty-four percent of those questioned further stated that they would now live "more healthy" than before enrolment in the ICSGK. In the subgroup of questioned insurants who had objective agreements with their doctors 45.4 % answered in this way. On the subject of cost-effectiveness, for both participating socil health insurance schemes, cost savings relative to the costs normally expected for the ICSGK population concerned are observed every year. In the seventh intervention year (2012) the total is 4.56 million Euros for the AOK Baden-Württemberg (BW), which is a contribution margin of 146 Euros per insurant for the 31.156 insurants concerned (LKK BW = 322 Euros per insurant relative to cost savings). The results presented in this paper indicate positive effects in all three Triple Aim dimensions. Further longitudinal studies are recommended to validate those first results together with a detailed analysis to obtain in-depth insights into the specific influence of subcomponents of the total intervention.

Effect of telehealth on hospital utilisation and mortality in routine clinical practice: a matched control cohort study in an early adopter site

OBJECTIVES

To assess the effects of a home-based telehealth intervention on the use of secondary healthcare and mortality.

DESIGN

Observational study of a mainstream telehealth service, using person-level administrative data. Time to event analysis (Cox regression) was performed comparing telehealth patients with controls who were matched using a machine-learning algorithm.

SETTING

A predominantly rural region of England (North Yorkshire).

PARTICIPANTS

716 telehealth patients were recruited from community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission. Patients were matched 1:1 to control patients, also selected from North Yorkshire, with respect to demographics, diagnoses of health conditions, previous hospital use and predictive risk score.

INTERVENTIONS

Telehealth involved the remote exchange of medical data between patients and healthcare professionals as part of the ongoing management of the patient's health condition. Monitoring centre staff alerted healthcare professionals if the telemonitored data exceeded preset thresholds. Control patients received usual care, without telehealth.

PRIMARY AND SECONDARY OUTCOME MEASURES

Time to the first emergency (unplanned) hospital admission or death. Secondary metrics included time to death and time to first admission, outpatient attendance and emergency department visit.

RESULTS

Matched controls and telehealth patients were similar at baseline. Following enrolment, telehealth patients were more likely than matched controls to experience emergency admission or death (adjusted HR 1.34, 95% CI 1.16 to 1.56, p<0.001). They were also more likely to have outpatient attendances (adjusted HR=1.25, 1.11 to 1.40, p<0.001), but mortality rates were similar between groups. Sensitivity analyses showed that we were unlikely to have missed reductions in the likelihood of an emergency admission or death because of unobserved baseline differences between patient groups.

CONCLUSIONS

Telehealth was not associated with a reduction in secondary care utilisation.

How a universal health system reduces inequalities: lessons from England

BACKGROUND

Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period.

METHODS

Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare.

RESULTS

Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare.

CONCLUSIONS

Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.

Are primary care factors associated with hospital episodes for adverse drug reactions? A national observational study

OBJECTIVE

Identification of primary care factors associated with hospital admissions for adverse drug reactions (ADRs).

DESIGN AND SETTING

Cross-sectional analysis of 2010-2012 data from all National Health Service hospitals and 7664 of 8358 general practices in England.

METHOD

We identified all hospital episodes with an International Classification of Diseases (ICD) 10 code indicative of an ADR, in the 2010-2012 English Hospital Episode Statistics (HES) admissions database. These episodes were linked to contemporary data describing the associated general practice, including general practitioner (GP) and patient demographics, an estimate of overall patient population morbidity, measures of primary care supply, and Quality and Outcomes Framework (QOF) quality scores. Poisson regression models were used to examine associations between primary care factors and ADR-related episode rates.

RESULTS

212,813 ADR-related HES episodes were identified. Rates of episodes were relatively high among the very young, older and female subgroups. In fully adjusted models, the following primary care factors were associated with increased likelihood of episode: higher deprivation scores (population attributable fraction (PAF)=0.084, 95% CI 0.067 to 0.100) and relatively poor glycated haemoglobin (HbA1c) control among patients with diabetes (PAF=0.372; 0.218 to 0.496). The following were associated with reduced episode likelihood: lower GP supply (PAF=-0.016; -0.026 to -0.005), a lower proportion of GPs with UK qualifications (PAF=-0.035; -0.058 to -0.012), lower total QOF achievement rates (PAF=-0.021; -0.042 to 0.000) and relatively poor blood pressure control among patients with diabetes (PAF=-0.144; -0.280 to -0.022).

CONCLUSIONS

Various aspects of primary care are associated with ADR-related hospital episodes, including achievement of particular QOF indicators. Further investigation with individual level data would help develop understanding of the associations identified. Interventions in primary care could help reduce the ADR burden. ADRs are candidates for primary care sensitive conditions.

Dementia in older people admitted to hospital: a regional multi-hospital observational study of prevalence, associations and case recognition

BACKGROUND

Previous studies have indicated a prevalence of dementia in older admissions of ∼42% in a single London teaching hospital, and 21% in four Queensland hospitals. However, there is a lack of published data from any European country on the prevalence of dementia across hospitals and between patient groups.

OBJECTIVE

To determine the prevalence and associations of dementia in older patients admitted to acute hospitals in Ireland.

METHODS

Six hundred and six patients aged ≥70 years were recruited on admission to six hospitals in Cork County. Screening consisted of Standardised Mini-Mental State Examination (SMMSE); patients with scores <27/30 had further assessment with the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Final expert diagnosis was based on SMMSE, IQCODE and relevant medical and demographic history. Patients were screened for delirium and depression, and assessed for co-morbidity, functional ability and nutritional status.

RESULTS

Of 598 older patients admitted to acute hospitals, 25% overall had dementia; with 29% in public hospitals. Prevalence varied between hospitals (P < 0.001); most common in rural hospitals and acute medical admissions. Only 35.6% of patients with dementia had a previous diagnosis. Patients with dementia were older and frailer, with higher co-morbidity, malnutrition and lower functional status (P < 0.001). Delirium was commonly superimposed on dementia (57%) on admission.

CONCLUSION

Dementia is common in older people admitted to acute hospitals, particularly in acute medical admissions, and rural hospitals, where services may be less available. Most dementia is not previously diagnosed, emphasising the necessity for cognitive assessment in older people on presentation to hospital.

Which hospitalisations are ambulatory care-sensitive, to what degree, and how could the rates be reduced? Results of a group consensus study in Germany

BACKGROUND

Much has been written lately regarding hospitalisations for ambulatory care-sensitive conditions (ACSH) and their strengths and weaknesses as a quality management indicator. The idea underlying ambulatory care-sensitive conditions (ACSC) is that effective treatment of acute conditions, good management of chronic illnesses and immunisation against infectious diseases can reduce the risk of a specified set of hospitalisations.

METHODS

The present paper applies group consensus methods to synthesise available evidence with expert opinion, thus identifying relevant ACSC. It contributes to the literature by evaluating the degree of preventability of ACSH and surveying the medical and systemic changes needed to increase quality for each diagnosis group. Forty physicians proportionally selected from all medical disciplines relevant to the treatment of ACSC participated in the three round Delphi survey. The setting of the study is Germany.

RESULTS

The proposed core list is a subset of 22 ACSC diagnosis groups, covering 90% of all consented ACSH and conditions with a higher than 85% estimated degree of preventability. Of all 18.6 million German hospital cases in the year 2012, the panelists considered 5.04 million hospitalisations (27%) to be sensitive to ambulatory care, of which 3.72 (20%) were estimated to be actually preventable. If only emergencies are considered, the ACSH share reduces to less than 8%. The geographic distribution of ACSH indicates significant regional variation with particularly high rates and potential for improvement in the North Rhine region, in Thuringia, Saxony-Anhalt, northern and eastern Bavaria and the Saarland. The average degree of preventability was 75% across all diagnosis groups. By far the most often mentioned strategy for reducing ACSH was 'improving continuous care'.

CONCLUSION

There are several good reasons why process indicators prevail in the assessment of ambulatory care. ACSH rates can however provide a more complete picture by adding useful information related to the overall patient outcome. The results of our analysis should be used to encourage debate and as a basis for further confirmatory work.

A systematic review of the magnitude and cause of geographic variation in unplanned hospital admission rates and length of stay for ambulatory care sensitive conditions

Background

Unplanned hospital admissions place a large and increasing strain on healthcare budgets worldwide. Many admissions for ambulatory care sensitive conditions (ACSCs) are thought to be preventable, a belief supported by significant geographic variations in admission rates. We conducted a systematic review of the evidence on the magnitude and correlates of geographic variation in ACSC admission rates and length of stay (LOS).

Methods

We performed a search of Medline and Embase databases for English language cross-sectional and cohort studies on 28th March 2013 reporting geographic variation in admission rates or LOS for patients receiving unplanned care across at least 10 geographical units for one of 35 previously defined ACSCs. Forward and backward citation searches were undertaken on all included studies. We provide a narrative synthesis of study findings. Study quality was assessed using a modified Newcastle-Ottawa scale.

Results

We included 39 studies comprising 25 on admission rates and 14 on LOS. Studies generally compared admission rates between regions (e.g. states) and LOS between hospitals. Most of the published research was undertaken in the US, UK or Canada and often focussed on patients with pneumonia, COPD or heart failure. 35 (90 %) studies concluded that geographic variation was present. Primary care quality and secondary care access were frequently suggested as drivers of admission rate variation whilst secondary care quality and adherence to clinical guidelines were often listed as contributors to LOS variation. Several different methods were used to quantify variation, some studies listed raw data, failed to control for confounders and used naive statistical methods which limited their utility.

Conclusions

The substantial geographical variations in the admission rates and LOS of potentially avoidable conditions could be a symptom of variable quality of care and should be a concern for clinicians and policymakers. Policymakers targeting a reduction in unplanned admissions could introduce initiatives to improve primary care access and quality or develop alternatives to admission. Those attempting to curb unnecessarily long LOS could introduce care pathways or guidelines. Methodological work on the quantification and reporting of geographic variation is needed to aid inter-study comparisons.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0964-3) contains supplementary material, which is available to authorized users.

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background

In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.

Objectives

To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.

Design

Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.

Participants

Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.

Results

Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.

Conclusions

Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.

Future work

Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.

Study registration

UK Clinical Reasearch Network 12960.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus

AIMS

To evaluate the impact of an integrated model of care for patients with complex Type 2 diabetes mellitus on potentially preventable hospitalizations.

METHODS

A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. Study and hospital admissions data were linked for the period from 12 months before to 24 months after commencement of the trial. The primary outcome was the number of potentially preventable hospitalizations with diabetes-related principal diagnoses. Length of stay once hospitalized was also reported.

RESULTS

Of 327 adult participants, 206 were hospitalized and accounted for 667 admissions during the study period. Compared with the usual care group, patients in the integrated model of care group were nearly half as likely to be hospitalized for a potentially preventable diabetes-related principal diagnosis in the 24 months after study commencement (incidence rate ratio 0.53, 95% CI 0.29, 0.96; P = 0.04). The magnitude of the result remained similar after adjusting for age, sex, education and baseline HbA1c concentration (incidence rate ratio 0.54, 95% CI 0.29, 1.01; P = 0.05).When hospitalized, patients in the integrated care group had a similar length of stay compared with those in the usual care group (median difference -2 days, 95% CI -6.5, 2.3; P = 0.33).

CONCLUSIONS

Patients receiving the integrated model of care had a reduction in the number of hospitalizations when the principal diagnosis for admission was a diabetes-related complication. Integrated models of care for people with complex diabetes can reduce hospitalizations and help attempts to curtail increasing demand on finite health services.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia

Supplemental Digital Content is available in the text.

Background:

Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions.

Objective:

To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization.

Methods:

Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization.

Results:

GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%).

Conclusions:

Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.

[Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure]

Objetivo

Comprobar si el proceso asistencial en Atención Primaria de Salud (APS), definido por 7 criterios de correcta atención, influye en el riesgo de hospitalizaciones evitables por Ambulatory Care Sensitive Conditions (ACSH) por insuficiencia cardíaca (IC).

Diseño

Estudio de casos y controles que analizó el riesgo de hospitalización por IC. Factor de exposición: proceso asistencial de APS.

Emplazamiento

Área sanitaria de la Comunidad de Madrid (n = 466.901).

Participantes

Pacientes mayores de 14 años con el registro del diagnóstico de IC en la historia clínica electrónica de APS (n = 3.277) antes del 1 de enero de 2007. Los casos fueron pacientes que ingresaron en el hospital de referencia por IC durante 2007. Los controles no requirieron ingreso.

Mediciones principales

Riesgo de ACSH por IC relacionado con el proceso asistencial considerado tanto de forma conjunta como por cada uno de los criterios. Diferencias en complejidad clínica mediante Adjusted Clinical Group (ACG).

Resultados

Doscientos veintisiete ingresos por IC frente a un grupo control de 3.050 pacientes. El peso medio de ACG fue mayor en los casos. Los controles tuvieron mayor cumplimentación de criterios, pero ninguno cumplió los 7. Solo en 2 de los criterios se observó menor riesgo de ACSH. A medida que no se cumplimentaba progresivamente cada criterio, el riesgo de ingresar aumentó (OR = 1,33; IC 95%: 1,19-1,49).

Conclusión

La calidad del proceso asistencial en APS influyó en el riesgo de ingreso por IC.

Variability in potentially preventable hospitalisations: an observational study of clinical practice patterns of general practitioners and care outcomes in the Basque Country (Spain)

OBJECTIVES

To explain the variability in the frequency of potentially preventable hospitalisations (ambulatory care sensitive conditions, ACSCs) based on factors at multiple levels (individual, health professional, health centre and health district), and specifically using resource efficiency indicators for general practitioners (GPs).

DESIGN

Cross-sectional study. We analysed primary care electronic health records and hospital discharge data using multilevel mixed models.

SETTING

Primary care network of the Basque Health Service (Spain).

PARTICIPANTS

All the residents in the Basque Country ≥14 years of age, covered by the public healthcare system (n=1,959,682), and all the GPs (n=1193) and health centres (n=130).

MAIN OUTCOME MEASURES

Individuals admitted for ACSCs, over a 12- month period.

RESULTS

Admissions for ACSCs were less frequent among patients who were female, middle-aged or from the highest socioeconomic classes. The health centre variables considered and GP list size were not found to be significant. After adjusting for the variables studied including morbidity, the risk of hospital admission was higher among individuals under the care of GPs with greater than expected numbers of patient visits and prescribing costs (OR=1.27 (95% CI 1.18 to 1.37); 1.16 (1.08 to 1.25)), and who make fewer referrals than the mean among their colleagues (OR=1.33 (1.22 to 1.44)).

CONCLUSIONS

When assessing activities and procedure indicators in primary care, we should also define outcome-based criteria. Specifically, GPs who are repeatedly visited by their patients, have higher prescribing costs and are more reluctant to refer patients to specialists obtain poorer outcomes.

The impact of office-based care on hospitalizations for ambulatory care sensitive conditions

OBJECTIVE

The aim of the study was to quantify the impact of specific medical services in the ambulatory sector (SA) on hospitalizations for ambulatory care sensitive conditions (ACSCs), in order to be able to assess whether and under what conditions specific ambulatory treatments could serve to lower the hospitalization rate.

DATA SOURCE

The analysis is based on administrative data showing the complete provision of medical services in the ambulatory sector in Germany and data from other sources. The data were provided by the National Association of Statutory Health Insurance Physicians, the Federal Statistical Agency, the Federal Office of Construction and Regional Planning, and the Federal Insurance Agency.

STUDY DESIGN

The impact of an increase in specific medical services on hospitalizations for ACSCs was estimated using linear spatial models at the level of the 413 German counties and county boroughs for the years 2007 and 2008. To allow for an undistorted estimation of the coefficients, SA and physician density were instrumented using a two-stage 'least squares' approach. The SA and the rate of hospitalizations for ACSCs were age-standardized. In the models, a well-defined set of covariates was controlled for.

PRINCIPAL FINDINGS

According to the models, an additional <euro> spent on ACSC treatment decreases the rate of hospitalizations for ACSCs for women and men up to an annual Uniform Value Scale For Doctors' Fees point value of approximately 6,891 and 5,735, respectively. The correlation is not linear but, as suspected, exhibits diminishing marginal returns.

CONCLUSIONS

Our models suggest that additional medical services reduce the rate of hospitalizations for ACSCs but that this correlation depends on the absolute level of office-based services in a county, all covariates being held equal. Ceteris paribus counties with a very high volume of services exhibit 'flat-of-the-curve medicine', while counties with a very low current level of specific medical services benefit most from an increase in those specific services.

Potentially avoidable hospital admissions in Germany: an analysis of factors influencing rates of ambulatory care sensitive hospitalizations

BACKGROUND

The concept of ambulatory care sensitive hospitalization (ACSH) is based on the assumption that hospitalization for certain conditions might have been avoided by the timely provision of appropriate care outside the hospital. As preventive care and early treatment are often carried out in the ambulatory setting, ACSH have come to be viewed as an indicator of quality for this sector of the health-care system.

METHOD

Factors potentially influencing the regional distribution of ACSH were examined for four conditions-congestive heart failure, angina pectoris, arterial hypertension, and diabetes mellitus-with separate analyses for men and women. A regression analysis was performed on the basis of German nationwide data for the year 2008 (hospital statistics and population statistics). The data covered all areas of Germany.

RESULTS

Each rise in the density of practice based specialists by 1 per 100,000 inhabitants was associated with a 0.1% reduction of ACSH in general and with a 0.3% reduction of ACSH for diabetes among men. A corresponding rise in the density of general practitioners was associated with reductions of ACSH among men by 0.1% for heart failure and by 0.5% for hypertension, yet also with increases of ACSH for angina pectoris (0.2% rise) and for diabetes (0.4% rise). Unemployment, residency in a rural area, and the number of hospital beds available locally were all positively correlated with small rises the ACSH rate. An age of 65 years and older was associated with the highest ACSH rates (0.7% to 3.6%).

CONCLUSION

Overall, the analyzed variables were only weakly associated with the frequency of ambulatory care sensitive hospitalization. Future studies should consider further aspects such as the quality of care, comorbidities, and participation in healthcare programs.

The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis

OBJECTIVES

To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss.

METHODS

Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance).

RESULTS

In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care.

CONCLUSION

In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.

Explaining variation in emergency admissions: a mixed-methods study of emergency and urgent care systems

Background

Recent increases in emergency admission rates have caused concern. Some emergency admissions may be avoidable if services in the emergency and urgent care system are available and accessible. A set of 14 conditions, likely to be rich in avoidable emergency admissions, was identified by expert consensus.

Objective

We aimed to understand variation in avoidable emergency admissions between different emergency and urgent care systems in England.

Methods

The design was a sequential mixed-methods study in three phases. In phase 1 we calculated an age- and sex-adjusted avoidable admission rate for 2008–11. We located routine data on characteristics of emergency and urgent care systems and used linear regression to explain variation in avoidable admissions rates in 150 systems. In phase 2 we undertook in-depth case studies in six systems to identify further factors. A key part of these case studies was interviews with commissioners, service providers and patient representatives, totalling 82 interviews. In phase 3 we returned to the linear regression to test further factors identified in the case studies.

Results

The 14 conditions accounted for 3,273,395 admissions in 2008–11 (22% of all emergency admissions). The mean age- and sex-adjusted admission rate was 2258 per year per 100,000 population, with a 3.4-fold variation between systems (1268–4359). Characteristics of the population explained the majority of variation: deprivation explained 72% of variation, with urban/rural status explaining 3% more. Systems serving populations with high levels of deprivation and in urban areas had high rates of potentially avoidable admissions. Interviewees described the complexity of deprivation, representing high levels of morbidity, low awareness of alternative services to emergency departments and high expressed need for immediate access to urgent care. Factors related to emergency departments (EDs), hospitals, emergency ambulance services and general practice explained a further 10% of variation in avoidable admissions. Systems with high, potentially avoidable, admission rates had high rates of acute beds (suggesting supply-induced demand), high rates of attendance at EDs (which have been associated with poor perceived access to general practice), high rates of conversion from ED attendances to admissions, and low rates of non-transport to emergency departments by emergency ambulances. The six case studies revealed further possible explanations of variation: there was variation in how hospitals coded admissions; some systems focused proactively on admission avoidance whereas others were more interested in hospital discharge, for example use of multidisciplinary teams based at acute trusts; there were different levels of integration between different services such as health and social care, and acute and community trusts; and some systems faced more challenging problems around geographical boundaries operating for different services in the system. Interviewees often described admission as the easy or safe option.

Conclusions

Deprivation explained most of the variation in avoidable admission rates. Research is needed to understand the complex relationship between deprivation and avoidable admission, and to develop interventions tailored to avoid admissions from deprived communities. Standardisation of coding of admissions would reduce variation.

Funding

The National Institute for Health Research Health Service and Research Delivery programme.

Social vulnerability index for the older people-Hong Kong and New York City as examples

Many world cities have suffered large-scale disasters, causing a significant loss of lives, property damage, and adverse social and economic impact. Those who are most vulnerable during and in the immediate aftermath of disaster crises are the elderly. Therefore, it is imperative to identify them and determine their specific needs in order to support them. Although several Social Vulnerability Indexes (SVIs) have been developed to assess different types of disaster vulnerability across geographic and population levels, few have been tailored to the older population. Building on the research of Gusmano et al., this study modifies and uses an SVI specifically designed to assess the vulnerability of older populations to emergencies and disasters across seven domains, namely, population size, institutionalization, poverty, living alone, disability, communication obstacles, and access to primary care. Moreover, it is acknowledged that availability of data largely depends on the local context and is always a barrier to production of indices across countries. The present study offers suggestions on how modifications can be made for local adaptation such that the SVI can be applied in different cities and localities. The SVI used in this study provides information to stakeholders in emergency preparedness, not only about natural disasters but also about health hazards and emergencies, which few existing SVI address.

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

OBJECTIVE

To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).

DESIGN

Controlled longitudinal study.

SETTING

English National Health Service between 1998/99 and 2010/11.

PARTICIPANTS

Populations registered with each of 6975 family practices in England.

MAIN OUTCOME MEASURES

Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.

RESULTS

Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11.

CONCLUSIONS

The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Preventable hospital admissions among the homeless in California: a retrospective analysis of care for ambulatory care sensitive conditions

Background

Limited research exists that investigates hospital admissions for ambulatory care sensitive conditions (ACSCs) among the homeless, who frequently lack a usual source of care. This study profiled ACSC admissions for homeless patients.

Methods

Bivariate analyses and logistic regression were completed to investigate ACSC and non-ACSC admissions among homeless patients using the 2010 California State Inpatient Database.

Results

Homeless patients admitted for an ACSC were mostly male, non-Hispanic white, and on average 49.9 years old. In the predictive model, the odds of an ACSC admission among homeless patients increased when they were black, admitted to the emergency department or transferred from another health facility. Having Medicare was associated with a decreased odds of an ACSC admission.

Conclusions

Specific characteristics are associated with a greater likelihood of an ACSC admission. Research should examine how these characteristics contribute to ACSC hospitalizations and findings should be linked to programs designed to serve as a safety-net for homeless patients to reduce hospitalizations.