Association of Population and Practice Factors with pOtentially Avoidable Admission Rates for Chronic Diseases in London: Cross Sectional Analysis

Using Ambulatory Care Sensitive Conditions to Assess Primary Health Care Performance during Disasters: A Systematic Review

Ambulatory care sensitive conditions (ACSCs) are health conditions for which appropriate primary care intervention could prevent hospital admission. ACSC hospitalization rates are a well-established parameter for assessing the performance of primary health care (PHC). Although this indicator has been extensively used to monitor the performance of PHC systems in peacetime, its consideration during disasters has been neglected. The World Health Organization (WHO) has acknowledged the importance of PHC in guaranteeing continuity of care during and after a disaster for avoiding negative health outcomes. We conducted a systematic review to evaluate the extent and nature of research activity on the use of ACSCs during disasters, with an eye toward finding innovative ways to assess the level of PHC function at times of crisis. Online databases were searched to identify papers. A final list of nine publications was retrieved. The analysis of the reviewed articles confirmed that ACSCs can serve as a useful indicator of PHC performance during disasters, with several caveats that must be considered. The reviewed articles cover several disaster scenarios and a wide variety of methodologies showing the connection between ACSCs and health system performance. The strengths and weaknesses of using different methodologies are explored and recommendations are given for using ACSCs to assess PHC performance during disasters.

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.

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.

Frequent avoidable admissions amongst Aboriginal and non-Aboriginal people with chronic conditions in New South Wales, Australia: a historical cohort study

BACKGROUND

Aboriginal and Torres Strait Islander people have high rates of avoidable hospital admissions for chronic conditions, however little is known about the frequency of avoidable admissions for this population. This study examined trends in avoidable admissions among Aboriginal and non-Aboriginal people with chronic conditions in New South Wales (NSW), Australia.

METHODS

A historical cohort analysis using de-identified linked administrative data of Aboriginal patients and an equal number of randomly sampled non-Aboriginal patients between 2005/06 to 2013/14. Eligible patients were admitted to a NSW public hospital and who had one or more of the following ambulatory care sensitive chronic conditions as a principal diagnosis: diabetic complications, asthma, angina, hypertension, congestive heart failure and/or chronic obstructive pulmonary disease. The primary outcomes were the number of avoidable admissions for an individual in each financial year, and whether an individual had three or more admissions compared with one to two avoidable admissions in each financial year. Poisson and logistic regression models and a test for differences in yearly trends were used to assess the frequency of avoidable admissions over time, adjusting for sociodemographic variables and restricted to those aged ≤75 years.

RESULTS

Once eligibility criteria had been applied, there were 27,467 avoidable admissions corresponding to 19,025 patients between 2005/06 to 2013/14 (71.2% Aboriginal; 28.8% non-Aboriginal). Aboriginal patients were 15% more likely than non-Aboriginal patients to have a higher number of avoidable admissions per financial year (IRR = 1.15; 95% CI: 1.11, 1.20). Aboriginal patients were almost twice as likely as non-Aboriginal patients to experience three or more avoidable admissions per financial year (OR = 1.90; 95% CI = 1.60, 2.26). There were no significant differences between Aboriginal and non-Aboriginal people in yearly trends for either the number of avoidable admissions, or whether or not an individual experienced three or more avoidable admissions per financial year (p = 0.859; 0.860 respectively).

CONCLUSION

Aboriginal people were significantly more likely to experience frequent avoidable admissions over a nine-year period compared to non-Aboriginal people. These high rates reflect the need for further research into which interventions are able to successfully reduce avoidable admissions among Aboriginal people, and the importance of culturally appropriate community health care.

Adherence to medical follow-up recommendations reduces hospital admissions: Evidence from diabetic patients in France

The aim of this study was to document the extent to which diabetic patients who adhered to required medical follow-ups in France experienced reduced hospital admissions over time. The main assumption was that enhanced monitoring and follow-up of diabetic patients in the primary care setting could be a substitute for hospital use. Using longitudinal claim data of diabetic patients between 2010 and 2015 from MGEN, a leading mutuelle insurance company in France, we estimated a dynamic logit model with lagged measures of the quality of adherence to eight medical follow-up recommendations. This model allowed us to disentangle follow-up care in hospitals from other forms of inpatient care that could occur simultaneously. We found that a higher adherence to medical guidance is associated with a lower probability of hospitalization and that the take-up of each of the eight recommendations may help reduce the rates of hospital admission. The reasons for the variation in patient adherence and implications for health policy are discussed.

Comorbidity prevalence among cancer patients: a population-based cohort study of four cancers

BACKGROUND

The presence of comorbidity affects the care of cancer patients, many of whom are living with multiple comorbidities. The prevalence of cancer comorbidity, beyond summary metrics, is not well known. This study aims to estimate the prevalence of comorbid conditions among cancer patients in England, and describe the association between cancer comorbidity and socio-economic position, using population-based electronic health records.

METHODS

We linked England cancer registry records of patients diagnosed with cancer of the colon, rectum, lung or Hodgkin lymphoma between 2009 and 2013, with hospital admissions records. A comorbidity was any one of fourteen specific conditions, diagnosed during hospital admission up to 6 years prior to cancer diagnosis. We calculated the crude and age-sex adjusted prevalence of each condition, the frequency of multiple comorbidity combinations, and used logistic regression and multinomial logistic regression to estimate the adjusted odds of having each condition and the probability of having each condition as a single or one of multiple comorbidities, respectively, by cancer type.

RESULTS

Comorbidity was most prevalent in patients with lung cancer and least prevalent in Hodgkin lymphoma patients. Up to two-thirds of patients within each of the four cancer patient cohorts we studied had at least one comorbidity, and around half of the comorbid patients had multiple comorbidities. Our study highlighted common comorbid conditions among the cancer patient cohorts. In all four cohorts, the odds of having a comorbidity and the probability of multiple comorbidity were consistently highest in the most deprived cancer patients.

CONCLUSIONS

Cancer healthcare guidelines may need to consider prominent comorbid conditions, particularly to benefit the prognosis of the most deprived patients who carry the greater burden of comorbidity. Insight into patterns of cancer comorbidity may inform further research into the influence of specific comorbidities on socio-economic inequalities in receipt of cancer treatment and in short-term mortality.

Predictors of hospitalizations for diabetes in Germany: an ecological study on a small-area scale

OBJECTIVES

Our objective was to evaluate the role of potential predictors in explaining spatial variation among diabetes hospitalization rates in Germany.

STUDY DESIGN

This was an ecological analysis using hospital routine data.

METHODS

County-level hospitalization rates (n = 402) in 2015 were calculated based on the German Diagnosis Related Groups database. We used a funnel plot to identify counties with high hospitalization rates. To examine the impact of predictors such as socio-economic status or structure of primary care, we performed linear and logistic regression analyses.

RESULTS

The crude hospitalization rate was 262 admissions per 100,000 population. In multivariable logistic models, we found the percentage of employees with academic degree (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.56-0.91), high hospital bed rate (4th quartile vs 1st quartile; OR: 2.73, CI: 1.03-7.24), and diabetes prevalence (OR: 1.49, CI: 1.17-1.90) to be significant predictors for high hospitalization rates. In multivariable linear models, the percentage of unemployed (regression coefficient b: 4.79, CI: 0.81-8.78) and rurality (b: 0.52, CI: 0.19-0.85) explained the variation in addition to predictors from logistic regression. Primary care structure was not a significant predictor in multivariable models.

CONCLUSIONS

The non-significant impact of primary care in adjusted models casts the use of diabetes hospitalizations as indicators for access and quality of primary care into doubt. Diabetes hospitalizations may rather reflect demand for care.

Avoidable hospitalizations in Brazil and Portugal: Identifying and comparing critical areas through spatial analysis

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics.

METHODS

An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas.

RESULTS

There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries.

CONCLUSION

Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.

The burden of preventable hospitalizations before and after implementation of the health transformation plan in a hospital in west of Iran

Background:

Increased number of preventable hospitalizations (PHs) for ambulatory care sensitive conditions (ACSCs) represents less efficiency and low access to outpatient and primary health care, leading to waste of health system resources.

Aim:

The purpose of this study is to assess the quality of outpatient and primary health care using the rate of PHs for ACSCs and to estimate the economic burden of ASCS before and after the implementation of the health transformation plan (HTP) in Iran.

Methods:

This research was a before–after quasi-experimental study. The study population included all patients hospitalized in the largest general hospital of Kurdistan province with five diseases such as asthma, diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease in 2014 (before the implementation of the HTP) and 2015 (after the implementation of the HTP). Data were analyzed by SPSS v.20 using Chi-square test.

Findings:

Total number of hospitalizations before and after the implementation of the HTP was 1501 and 1405, respectively. Moreover, the proportion of PHs in all types of the hospital admissions before and after the implementation of the HTP was 47% and 49%, respectively. There was no statistically significant difference between the number of PHs before and after the HTP. In total, PHs imposed 885 798 US$ and 9920 bed-days on health system before and after the implementation of the HTP.

Conclusion:

Despite the previous expectations of policy makers for improving quality, efficiency, and access to primary health care through implementation of the HTP, proportion of PHs is considerable and it imposes a lot of costs and bed-days on the health system both before and after the HTP.

Quality of diabetes follow-up care and hospital admissions

Diabetes may lead to severe complications. For this reason, disease prevention and improvement of medical follow-up represent major public health issues. The aim of this study was to measure the impact of adherence to French follow-up guidelines on hospitalization of people with diabetes. We used insurance claims data from the years 2010 to 2013 collected for 52,027 people aged over 18, affiliated to a French social security provider and treated for diabetes. We estimated panel data models to explore the association between adherence to guidelines and different measures of hospitalization, controlling for socioeconomic characteristics, diabetes treatment and density of medical supply. The results show that adherence to four guidelines was associated with a significant decrease in hospital admissions, up to approximatively 30% for patients monitored for a complete lipid profile or microalbuminuria during the year. In addition, our analyses confirmed the strong protective effect of income and a significant positive correlation with good supply of hospital care. In conclusion, good adherence to French diabetes guidelines seems to be in line with the prevention of health events, notably complications, that could necessitate hospitalization.

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.

Variation in avoidable emergency admissions: multiple case studies of emergency and urgent care systems

OBJECTIVE

To identify factors affecting variation in avoidable emergency admissions that are not usually identified in statistical regression.

METHODS

As part of an ethnographic residual analysis, we compared six emergency and urgent care systems in England, interviewing 82 commissioners and providers of key emergency and urgent care services.

RESULTS

There was variation between the six cases in how interviewees described three parts of their emergency and urgent care systems. First, interviewees' descriptions revealed variation in the availability of services before patients decided to attend emergency departments. Poor availability of general practice out of hours services in some of the cases reportedly made attendance at emergency departments the easier option for patients. Second, there was variation in how interviewees described patients being dealt with during their emergency department visit in terms of availability of senior review by specialists and in coding practices when patients were at risk of breaching the NHS's 4-hour waiting time target. Third, there was variability in services described as facilitating discharge home from emergency departments. In some cases, emergency department staff described dealing with multiple agencies in multiple localities outside the hospital, making admission the easier option. In other cases, proactive multidisciplinary rapid assessment teams were described as available to avoid admissions. Perceptions of resources available out of hours and the extent of integration between different health services, and between health and social services, also differed by case.

CONCLUSIONS

This comparative case study approach identified further factors that may affect avoidable emergency admissions. Initiatives to improve GP out of hours services, make coding more accurately reflect patient experience, increase senior review in emergency departments, offer proactive multidisciplinary admission avoidance teams, improve the availability of out of hours care in the wider emergency and urgent care system, and increase service integration may reduce avoidable admissions. Evaluation of such initiatives would be necessary before wide-scale adoption.

Hospital characteristics affecting potentially avoidable emergency admissions: national ecological study

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by emergency and urgent care services without resorting to admission to a hospital bed. In England, these services include hospitals, emergency ambulance, and a range of primary and community services. The aim was to identify whether characteristics of hospitals affect potentially avoidable emergency admission rates. An age-sex adjusted rate of admission for 14 conditions rich in avoidable emergency admissions was calculated for 129 hospitals in England for 2008-2011. Twenty-two per cent (3,273,395/14,998,773) of emergency admissions were classed as potentially avoidable, with threefold variation between hospitals. Explanatory factors of this variation included those which hospital managers could not control (demand for hospital emergency departments) and those which they could control (supply in terms of numbers of acute beds in the hospital, and management of non-emergency and emergency patients within the hospital). Avoidable admission rates were higher for hospitals with higher emergency department attendance rates, higher numbers of acute beds per 1000 catchment population and higher conversion rates from emergency department attendance to admission. Hospital managers may be able to reduce avoidable emergency admissions by reducing supply of acute beds and conversion rates from emergency department attendance.

Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children

BACKGROUND

There are several treatment options for managing acute asthma exacerbations (sustained worsening of symptoms that do not subside with regular treatment and require a change in management). Guidelines advocate the use of inhaled short acting beta2-agonists (SABAs) in children experiencing an asthma exacerbation. Anticholinergic agents, such as ipratropium bromide and atropine sulfate, have a slower onset of action and weaker bronchodilating effect, but may specifically relieve cholinergic bronchomotor tone and decrease mucosal edema and secretions. Therefore, the combination of inhaled anticholinergics with SABAs may yield enhanced and prolonged bronchodilation.

OBJECTIVES

To determine whether the addition of inhaled anticholinergics to SABAs provides clinical improvement and affects the incidence of adverse effects in children with acute asthma exacerbations.

SEARCH METHODS

We searched MEDLINE (1966 to April 2000), EMBASE (1980 to April 2000), CINAHL (1982 to April 2000) and reference lists of studies of previous versions of this review. We also contacted drug manufacturers and trialists. For the 2012 review update, we undertook an 'all years' search of the Cochrane Airways Group's register on the 18 April 2012.

SELECTION CRITERIA

Randomized parallel trials comparing the combination of inhaled anticholinergics and SABAs with SABAs alone in children (aged 18 months to 18 years) with an acute asthma exacerbation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We used the GRADE rating system to assess the quality of evidence for our primary outcome (hospital admission).

MAIN RESULTS

Twenty trials met the review eligibility criteria, generated 24 study comparisons and comprised 2697 randomised children aged one to 18 years, presenting predominantly with moderate or severe exacerbations. Most studies involved both preschool-aged children and school-aged children; three studies also included a small proportion of infants less than 18 months of age. Nine trials (45%) were at a low risk of bias. Most trials used a fixed-dose protocol of three doses of 250 mcg or two doses of 500 mcg of nebulized ipratropium bromide in combination with a SABA over 30 to 90 minutes while three trials used a single dose and two used a flexible-dose protocol according to the need for SABA.The addition of an anticholinergic to a SABA significantly reduced the risk of hospital admission (risk ratio (RR) 0.73; 95% confidence interval (CI) 0.63 to 0.85; 15 studies, 2497 children, high-quality evidence). In the group receiving only SABAs, 23 out of 100 children with acute asthma were admitted to hospital compared with 17 (95% CI 15 to 20) out of 100 children treated with SABAs plus anticholinergics. This represents an overall number needed to treat for an additional beneficial outcome (NNTB) of 16 (95% CI 12 to 29).Trends towards a greater effect with increased treatment intensity and with increased asthma severity were observed, but did not reach statistical significance. There was no effect modification due to concomitant use of oral corticosteroids and the effect of age could not be explored. However, exclusion of the one trial that included infants (< 18 months) and contributed data to the main outcome, did not affect the results. Statistically significant group differences favoring anticholinergic use were observed for lung function, clinical score at 120 minutes, oxygen saturation at 60 minutes, and the need for repeat use of bronchodilators prior to discharge from the emergency department. No significant group difference was seen in relapse rates.Fewer children treated with anticholinergics plus SABA reported nausea and tremor compared with SABA alone; no significant group difference was observed for vomiting.

AUTHORS' CONCLUSIONS

Children with an asthma exacerbation experience a lower risk of admission to hospital if they are treated with the combination of inhaled SABAs plus anticholinergic versus SABA alone. They also experience a greater improvement in lung function and less risk of nausea and tremor. Within this group, the findings suggested, but did not prove, the possibility of an effect modification, where intensity of anticholinergic treatment and asthma severity, could be associated with greater benefit.Further research is required to identify the characteristics of children that may benefit from anticholinergic use (e.g. age and asthma severity including mild exacerbation and impending respiratory failure) and the treatment modalities (dose, intensity, and duration) associated with most benefit from anticholinergic use better.

Methodological challenges of measuring primary care delivery to pediatric medicaid beneficiaries who use community health centers

Efforts to measure quality of care have focused on ambulatory care providers. We examined the performance of community health centers serving children on Medicaid in 3 states. Descriptive analysis showed considerable patient population heterogeneity, and regression analysis demonstrated that variation explained by the assigned provider was small (mean R(2) = 4.3%) compared with the variation explained by patient demographic variables (mean R(2) = 29.9%). The results reinforce the need for caution when one is attributing quality differences to provider performance.

Primary care access and its relationship with emergency department utilisation: an observational, cross-sectional, ecological study

BACKGROUND

Recent health service policies in the UK have focused on improving primary care access in order to reduce the use of costly emergency department services, even though the relationship between the two is based on weak or little evidence. Research is required to establish whether improving primary care access can influence emergency department attendance.

AIM

To ascertain whether a relationship exists between the degree of access to GP practices and avoidable emergency department attendances in an inner-London primary care trust (PCT).

DESIGN AND SETTING

Observational, cross-sectional ecological study in 68 general practices in Brent Primary Care Trust, north London, UK.

METHOD

GP practices were used as the unit of analysis and avoidable emergency department attendance as the dependent variable. Routinely collected data from GP practices, Hospital Episode Statistics, and census data for the period covering 2007-2009 were used across three broad domains: GP access characteristics, population characteristics, and health status aggregated to the level of the GP practice. Multiple linear regression was used to ascertain which variables account for the variation in emergency department attendance experienced by patients registered to each GP practice.

RESULTS

None of the GP access variables accounted for the variation in emergency department attendance. The only variable that explained this variance was the Index of Multiple Deprivation (IMD). For every unit increase in IMD score of the GP practice, there would be an increase of 6.13 (95% CI = 4.56, 7.70) per 1000 patients per year in emergency department attendances. This accounted for 47.9% of the variance in emergency department attendances in Brent.

CONCLUSION

Avoidable emergency department attendance appears to be mostly driven by underlying deprivation rather than by the degree of access to primary care.

Hospitalizations for ambulatory care sensitive conditions and quality of primary care: their relation with socioeconomic and health care variables in the Madrid regional health service (Spain)

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions (ACSH) have been proposed as an indirect indicator of the effectiveness and quality of care provided by primary health care.

OBJECTIVE

To investigate the association of ACSH rates with population socioeconomic factors and with characteristics of primary health care.

RESEARCH DESIGN

Cross-sectional, ecologic study. Using hospital discharge data, ACSH were selected from the list of conditions validated for Spain.

SETTING

All 34 health districts in the Region of Madrid, Spain.

SUBJECTS

Individuals aged 65 years or older residing in the region of Madrid between 2001 and 2003, inclusive.

MEASURES

Age- and gender-adjusted ACSH rates in each health district.

RESULTS

The adjusted ACSH rate per 1000 population was 35.37 in men and 20.45 in women. In the Poisson regression analysis, an inverse relation was seen between ACSH rates and the socioeconomic variables. Physician workload was the only health care variable with a statistically significant relation (rate ratio of 1.066 [95% CI; 1.041-1.091]). These results were similar in the analyses disaggregated by gender. In the multivariate analyses that included health care variables, none of the health care variables were statistically significant.

CONCLUSIONS

ACSH may be more closely related with socioeconomic variables than with characteristics of primary care activity. Therefore, other factors outside the health system must be considered to improve health outcomes in the population.

Does higher quality of diabetes management in family practice reduce unplanned hospital admissions?

OBJECTIVE

To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes.

STUDY SETTING

A total of 8,223 English family practices from 2001/2002 to 2006/2007.

STUDY DESIGN

Multiple regression analyses of associations between admissions and proportions of practice diabetic patients with good (glycated hemoglobin [HbA1c] ≤7.4 percent) and moderate (7.4 percent <HbA1c ≤10 percent) glycemic control. Covariates included diabetes prevalence, baseline admission rates, socioeconomic, demographic, and geographic characteristics.

DATA

Practice quality measures extracted from practice records linked with practice-level hospital admissions data and practice-level covariates data.

PRINCIPAL FINDINGS

Practices with 1 percent more patients with moderate rather than poor glycemic control on average had 1.9 percent (95 percent CI: 1.1-2.6 percent) lower rates of emergency admissions for acute hyperglycemic complications. Having more patients with good rather than moderate control was not associated with lower admissions. There was no association of moderate or good control with hypoglycemic admissions.

CONCLUSION

Cross-sectionally, family practices with better quality of diabetes care had fewer emergency admissions for short-term complications of diabetes. Over time, after controlling for national trends in admissions, improvements in quality in a family practice were associated with a reduction in its admissions.

Life course social mobility and risk of upper aerodigestive tract cancer in men

The aim of this study was to explore associations between social mobility and tumours of the upper aero-digestive tract (UADT), focussing on life-course transitions in social prestige (SP) based on occupational history. 1,796 cases diagnosed between 1993 and 2005 in ten European countries were compared with 1585 controls. SP was classified by the Standard International Occupational Prestige Scale (SIOPS) based on job histories. SIOPS was categorised in high (H), medium (M) and low (L). Time weighted average achieved and transitions between SP with nine trajectories: H --> H, H --> M, H --> L, M --> H, M --> M, M --> L, L --> H, L --> M and L --> L were analysed. Odds ratios (ORs) and 95%-confidence intervals [95%-CIs] were estimated with logistic regression models including age, consumption of fruits/vegetables, study centre, smoking and alcohol consumption. The adjusted OR for the lowest versus the highest of three categories (time weighted average of SP) was 1.28 [1.04-1.56]. The distance of SP widened between cases and controls during working life. The downward trajectory H --> L gave an OR of 1.71 [0.75-3.87] as compared to H --> H. Subjects with M --> M and L --> L trajectories ORs were also elevated relative to subjects with H --> H trajectories. The association between SP and UADT is not fully explained by confounding factors. Downward social trajectory during the life course may be an independent risk factor for UADT cancers.

Quality of primary care and hospital admissions for diabetes mellitus in England

The National Health Service in England has invested substantially in recent years to improve the quality of primary care services for patients with chronic diseases such as diabetes. A key aim of this investment is to reduce associated complication rates and decrease consequent hospital admission rates. The goal of the study was to examine associations between the quality of primary care services and hospital admission rates for diabetes mellitus in England. An ecological cross-sectional study design was used. Three hundred three primary care trusts in England participated in the public reporting and performance-linked reimbursement of quality measures, including measures relevant to diabetes care. A total of 1,760,898 persons with diabetes registered with 8441 family practices in England. Hospital admission rates (total admissions for diabetes, admissions for ketoacidosis) were compared with quality of care scores, diabetes prevalence and neighborhood socio-economic status. We found a 10-fold variation across the country in total admissions for diabetes despite uniformly high scores on quality measures over the first year of the new family practitioner contract. Significant but weak inverse associations were found between primary care quality scores and hospital admission rates in patients aged 60 years and older, with a correlation coefficient of -0.21 (P < .001) between glycemic control and total admissions. Neighborhood socioeconomic status was more strongly correlated with total hospital admission rates than quality scores in patients aged 25-59 years (r = 0.58; P < .001) and 60 years and older (r = 0.45; P < .001). Quality of care scores and prevalence data were available only at the practice level rather than at the patient level. Improving the quality of primary care services may lead to modest reductions in demand for hospital services among older patients with diabetes. However, low neighborhood socioeconomic status is more strongly associated with hospital admission rates for diabetes.

Identifying patients at high risk of emergency hospital admissions: a logistic regression analysis

OBJECTIVE

To use routine data to identify patients at high risk of future emergency hospital admissions.

DESIGN

Descriptive analysis of inpatient hospital episode statistics. Predictive model developed using multiple logistic regression.

SETTING

National Health Service hospital trusts in England.

PARTICIPANTS

All patients with an emergency admission to an NHS hospital between 1 April 2000 and 31 March 2001.

MAIN OUTCOME MEASURES

'High-impact users' were defined as patients who had at least one emergency inpatient admission and who then went on to have at least two further emergency hospital admissions in the 12 months following the start date of that index admission.

RESULTS

2,895,234 patients were admitted as emergencies in 2000/2001, of whom 147,725 (5.1%) did not survive their first spell. Of the 2,747,509 surviving patients, 269,686 (9.8%) subsequently had at least two or more emergency admissions within 365 days of the index date of admission. A further 236,779 (8.6%) died during this period. Risk factors for becoming a high-impact user included the number of emergencies in the 36 months before index spell, comorbidity, age, an admission for an ambulatory care sensitive condition, ethnicity, area-level socioeconomic data, local admission rates, the number of episodes in the index spell, sex and the source of admission. The predictive model based on all emergency admissions produced a receiver operating characteristic curve score of 0.72.

CONCLUSIONS

Routine hospital episode statistics can be used to identify patients who are at high risk of suffering future multiple emergency hospital admissions. The potential cost savings in preventing a proportion of these subsequent admissions need to be compared with the costs of case management of these patients.