Demographic and clinical predictors of unplanned hospital utilisation among chronically ill patients: a prospective cohort study

Measuring the impact of an acute visiting scheme on emergency department attendances - a pre-post cohort design

BACKGROUND

Emergency department (ED) attendances are contributing to rising costs of the National Health Service (NHS) in England. Critically assessing the impact of new services to reduce emergency department use can be difficult as new services may create additional access points, unlocking latent demand. The study evaluated an Acute Visiting Scheme (AVS) in a primary care context. We asked if AVS reduces overall ED demand and whether or not it changed utilisation patterns for frequent attenders.

METHOD

The study used a pre post single cohort design. The impact of AVS on all-cause ED attendances was hypothesised as a substitution effect, where AVS duty doctor visits would replace emergency department visits. Primary outcome was frequency of ED attendances. End points were reduction of frequency of service use and increase of intervals between attendances by frequent attenders.

RESULTS

ED attendances for AVS users rose by 47.6%. If AVS use was included, there was a more than fourfold increase of total service utilisation, amounting to 438.3%. It shows that AVS unlocked significant latent demand. However, there was some reduction in the frequency of ED attendances for some patients and an increase in time intervals between ED attendances for others.

CONCLUSION

The study demonstrates that careful analysis of patient utilisation can detect a differential impact of AVS on the use of ED. As the new service created additional access points for patients and hence introduces an element of choice, the new service is likely to unlock latent demand. This study illustrates that AVS may be most useful if targeted at specific patient groups who are most likely to benefit from the new service.

Registered nurses' perceptions of safe care in overcrowded emergency departments

AIMS AND OBJECTIVES

To explore registered nurses' perceptions of safe practice in care for patients with an extended length of stay in the emergency department.

BACKGROUND

Extended length of stay and overcrowding in emergency departments are described internationally as one of the most comprehensive challenges of modern emergency care. An emergency department is not designed, equipped or staffed to provide care for prolonged periods of time. This context, combined with a high workload, poses a risk to patient safety, with additional medical errors and an increased number of adverse events. From this perspective, it is important to extend our knowledge and to describe registered nurses' experiences of safe practice.

DESIGN

A qualitative, inductive and descriptive study.

METHODS

Qualitative interview study carried out in five emergency departments. Data were analysed using a qualitative content analysis with a latent approach.

RESULTS

Patient safety meets obstacles in the clinical environment involving experiencing deficiencies regarding patient safety in the clinical setting and the impact of working procedures and routines. Moreover, nurses are challenged in their professional responsibilities involving balancing essential nursing care and actual workload; it is common to experience emotional reactions based on feelings of loss of control.

CONCLUSIONS

From the nurses' perspective, a prolonged stay in the emergency department may lead to negative consequences for both patient safety and care as well as registered nurses' psychosocial experiences. An extended length of stay significantly reduces the level of nursing and caring that registered nurses can perform in the emergency department.

RELEVANCE TO CLINICAL PRACTICE

This study indicates that emergency departments should review their procedures to avoid both deviations from normal practice and moral stress among registered nurses. This can contribute to an increased understanding and insight about the challenge of patient safety in an emergency department setting.

Mortality reductions from marginal increases in public spending on health

There is limited empirical evidence of the nature of any relationship between health spending and health outcomes in Australia. We address this by estimating the elasticity of health outcomes with respect to public healthcare spending using an instrumental variable (IV) approach to account for endogeneity of healthcare spending to health outcomes. Results suggest that, based on the conditional mean, a 1% increase in public health spending was associated with a 2.2% (p < 0.05) reduction in the number of standardised Years of Life Lost (YLL). Sensitivity analyses and robustness checks supported this conclusion. Further exploration using IV quantile regression indicated that marginal returns on public health spending were significantly greater for areas with poorer health outcomes compared to areas with better health outcomes. On average, marginal increases in public health spending reduce YLL, but areas with poorer health outcomes have the greatest potential to benefit from the same marginal increase in public health spending compared to areas with better health outcomes. Understanding the relationship between health spending and outcomes and how this differs according to baseline health outcomes can help meet dual policy objectives to improve the productivity of the healthcare system and reduce inequity.

Functional status and annual hospitalization in multimorbid and non-multimorbid older adults: a cross-sectional study in Southern China

Background

Hospitalization over the last one year, an indicator of health service utilization, is an important and costly resource in older adult care. However, data on the relationship between functional status and annual hospitalization among older Chinese people are sparse, particularly for those with and without multimorbidity. In this study,we aimed to examine the association between functional status and annual hospitalization among community-dwelling older adults in Southern China, and to explore the independent contributions of socio-demographic variables, lifestyle and health-related factors and functional status to hospitalization in multimorbid and non-multimorbid groups.

Methods

This cross-sectional, community-based survey, studied 2603 older adults aged 60 years and above. Functional status was assessed by Functional Independence Measure (FIM). The outcome variable was any hospitalization over the last one year (annual hospitalization). Clustered logistic regression was used to analyze the independent contributions of FIM domains to annual hospitalization.

Results

Only in the multimorbid group, did the risk of annual hospitalization decrease significantly with increasing FIM score in walk domain (adjusted OR = 0.80 per SD increase, 95% CI = 0.70–0.91, P = 0.001) and its independent contribution accounted for 24.62%, more than that of socio-demographic variables (18.46%). However, among individuals without multimorbidity, there were no significant associations between FIM domains and annual hospitalization; thus, no independent contribution to the risk of hospitalization was observed.

Conclusions

There exist some degree of correlation between functional status and annual hospitalization among older adults in Southern China, which might be due to the presence of multimorbidity with advanced age.

Emergency department utilisation among older people with acute and/or chronic conditions: A multi-centre retrospective study

INTRODUCTION

Older persons aged over 65years represent up to 41% of Australian Emergency Department (ED) presentations. Older persons present with acute and/or chronic conditions, have more Emergency Department visits, hospital admissions and readmissions than other age groups. However, little is known about the characteristics and trends of acute illness and chronic presentations and whether frailty changes these dimensions within this cohort.

METHODS

A 12-month retrospective medical record audit of persons over 65years presenting to four EDs.

RESULTS

Data from 44,774 (26.6%) patients aged 65years and over were analysed. Patients with acute conditions presented more frequently (n=30,373; 67.8%), received more urgent triage categories (n=13,471; 30.1%) and had higher admission rates (n=18,332; 61%). Chronic conditions presented less frequently (n=14,396; 32.1%) and had higher discharge rates (n=9302; 65%). Patients over 80years were allocated more urgent triage categories and commonly presented with falls (n=3814; 8.5%). Patients between 65 and79years had a higher discharge rate (n=10,397; 46.1%).

CONCLUSION

Older persons with acute illnesses were more likely to be admitted than those with chronic conditions and who were more likely to be discharged home. There is scope for further investigation of new models of care to better manage older persons with chronic conditions and ED discharge practices.