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Population and patient factors affecting emergency department attendance in London: retrospective cohort analysis of linked primary and secondary care records. Br J Gen Pract 2018; 68:e157-e167. [PMID: 29335325 DOI: 10.3399/bjgp18x694397] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/11/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Population factors, including social deprivation and morbidity, predict the use of emergency departments (EDs). AIM To link patient-level primary and secondary care data to determine whether the association between deprivation and ED attendance is explained by multimorbidity and other clinical factors in the GP record. DESIGN AND SETTING Retrospective cohort study based in East London. METHOD Primary care demographic, consultation, diagnostic, and clinical data were linked with ED attendance data. GP Patient Survey (GPPS) access questions were linked to practices. RESULTS Adjusted multilevel analysis for adults showed a progressive rise in ED attendance with increasing numbers of long-term conditions (LTCs). Comparing two LTCs with no conditions, the odds ratio (OR) is 1.28 (95% confidence interval [CI] = 1.25 to 1.31); comparing four or more conditions with no conditions, the OR is 2.55 (95% CI = 2.44 to 2.66). Increasing annual GP consultations predicted ED attendance: comparing zero with more than two consultations, the OR is 2.44 (95% CI = 2.40 to 2.48). Smoking (OR 1.30, 95% CI = 1.28 to 1.32), being housebound (OR 2.01, 95% CI = 1.86 to 2.18), and age also predicted attendance. Patient-reported access scores from the GPPS were not a significant predictor. For children, younger age, male sex, white ethnicity, and higher GP consultation rates predicted attendance. CONCLUSION Using patient-level data rather than practice-level data, the authors demonstrate that the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.
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Al-Mahtot M, Barwise-Munro R, Wilson P, Turner S. Changing characteristics of hospital admissions but not the children admitted-a whole population study between 2000 and 2013. Eur J Pediatr 2018; 177:381-388. [PMID: 29260375 PMCID: PMC5816774 DOI: 10.1007/s00431-017-3064-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED There are increasing numbers of emergency medical paediatric admissions. Our hypothesis was that characteristics of children and details of their emergency admissions are also changing over time. Details of emergency admissions in Scotland 2000-2013 were analysed. There were 574,403 emergency admissions, median age 2.3 years. The age distribution, proportion of boys and socioeconomic status of children admitted were essentially unchanged. Emergency admissions rose by 49% from 36/1000 children per annum to 54/1000 between 2000 and 2013. Emergency admissions that were discharged on the same day rose by 186% from 8.6/1000 to 24.6/1000. The mean duration of emergency admission fell from 1.7 to 1.0 days. The odds for an emergency admission with upper respiratory infection, "viral infection", tonsillitis, bronchiolitis and lower respiratory tract infection all rose. In contrast the odds for an emergency admission with asthma and gastroenteritis fell. CONCLUSIONS The demographics of children with emergency admissions have not changed substantially but characteristics of admissions have changed considerably, in particular admissions which are short stay and due to respiratory infection are much more common. The fall in the absolute number of children with some acute medical diagnoses suggests that the rise in admissions is not necessarily inexorable. What is Known: • Emergency admission prevalence is rising in many countries across Europe. What is New: • Our paper is the first to comprehensively analyse emergency medical paediatric admissions by exploring how characteristics of admissions and the children admitted have changed over time for a whole population. • The "take home message" is that whilst characteristics of emergency admissions have changed (e.g. number, duration of stay, readmissions, diagnoses), the characteristics of the children have not changed.
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Affiliation(s)
- Maryam Al-Mahtot
- Child Health, Royal Aberdeen Children’s Hospital, Aberdeen, AB25 2ZG UK
| | | | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, UK
| | - Steve Turner
- Child Health, Royal Aberdeen Children's Hospital, Aberdeen, AB25 2ZG, UK.
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Lawn S, Zabeen S, Smith D, Wilson E, Miller C, Battersby M, Masman K. Managing chronic conditions care across primary care and hospital systems: lessons from an Australian Hospital Avoidance Risk Program using the Flinders Chronic Condition Management Program. AUST HEALTH REV 2018; 42:542-549. [DOI: 10.1071/ah17099] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 07/10/2017] [Indexed: 11/23/2022]
Abstract
Objective
The study aimed to determine the impact of the Flinders Chronic Condition Management Program for chronic condition self-management care planning and how to improve its use with Bendigo Health’s Hospital Admission Risk Program (HARP).
Methods
A retrospective analysis of hospital admission data collected by Bendigo Health from July 2012 to September 2013 was undertaken. Length of stay during admission and total contacts post-discharge by hospital staff for 253 patients with 644 admissions were considered as outcome variables. For statistical modelling we used the generalised linear model.
Results
The combination of the HARP and Flinders Program was able to achieve significant reductions in hospital admissions and non-significant reduction in emergency department presentations and length of stay. The generalised linear model predicted that vulnerable patient groups such as those with heart disease (P = 0.037) and complex needs (P < 0.001) received more post-discharge contacts by HARP staff than those suffering from diabetes, renal conditions and psychosocial needs when they lived alone. Similarly, respiratory (P < 0.001), heart disease (P = 0.015) and complex needs (P = 0.050) patients had more contacts, with an increased number of episodes than those suffering from diabetes, renal conditions and psychosocial needs.
Conclusion
The Flinders Program appeared to have significant positive impacts on HARP patients that could be more effective if high-risk groups, such as respiratory patients with no carers and respiratory and heart disease patients aged 0–65, had received more targeted care.
What is known about the topic?
Chronic conditions are common causes of premature death and disability in Australia. Besides mental and physical impacts at the individual level, chronic conditions are strongly linked to high costs and health service utilisation. Hospital avoidance programs such as HARP can better manage chronic conditions through a greater focus on coordination and integration of care across primary care and hospital systems. In support of HARP, self-management interventions such as the Flinders Program aim to help individuals better manage their medical treatment and cope with the impact of the condition on their physical and mental wellbeing and thus reduce health services utilisation.
What does this paper add?
This paper sheds light on which patients might be more or less likely to benefit from the combination of the HARP and Flinders Program, with regard to their impact on reductions in hospital admissions, emergency department presentations and length of stay. This study also sheds light on how the Flinders Program could be better targeted towards and implemented among high-need and high-cost patients to lessen chronic disease burden on Australia’s health system.
What are the implications for practitioners?
Programs targeting vulnerable populations and applying evidence-based chronic condition management and self-management support achieve significant reductions in potentially avoidable hospitalisation and emergency department presentation rates, though sex, type of chronic condition and living situation appear to matter. Benefits might also accrue from the combination of contextual factors (such as the Flinders Program, supportive service management, clinical champions in the team) that work synergistically.
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104
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Broadway B, Kalb G, Li J, Scott A. Do Financial Incentives Influence GPs' Decisions to Do After-hours Work? A Discrete Choice Labour Supply Model. HEALTH ECONOMICS 2017; 26:e52-e66. [PMID: 28217847 DOI: 10.1002/hec.3476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 10/14/2016] [Accepted: 12/01/2016] [Indexed: 06/06/2023]
Abstract
This paper analyses doctors' supply of after-hours care (AHC), and how it is affected by personal and family circumstances as well as the earnings structure. We use detailed survey data from a large sample of Australian General Practitioners (GPs) to estimate a structural, discrete choice model of labour supply and AHC. This allows us to jointly model GPs' decisions on the number of daytime-weekday working hours and the probability of providing AHC. We simulate GPs' labour supply responses to an increase in hourly earnings, both in a daytime-weekday setting and for AHC. GPs increase their daytime-weekday working hours if their hourly earnings in this setting increase, but only to a very small extent. GPs are somewhat more likely to provide AHC if their hourly earnings in that setting increase, but again, the effect is very small and only evident in some subgroups. Moreover, higher earnings in weekday-daytime practice reduce the probability of providing AHC, particularly for men. Increasing GPs' earnings appears to be at best relatively ineffective in encouraging increased provision of AHC and may even prove harmful if incentives are not well targeted. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Barbara Broadway
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
| | - Guyonne Kalb
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
- Institute for the Study of Labor (IZA), Bonn, Germany
| | - Jinhu Li
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
- ARC Centre of Excellence for Children and Families over the Life Course, Indooroopilly, QLD, Australia
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Melbourne, VIC, Australia
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105
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Feng D, Zhang D, Li B, Zhang Y, Serrano R, Shi D, Liu Y, Zhang L. Does having a usual primary care provider reduce patient self-referrals in rural China's rural multi-tiered medical system? A retrospective study in Qianjiang District, China. BMC Health Serv Res 2017; 17:778. [PMID: 29179717 PMCID: PMC5704594 DOI: 10.1186/s12913-017-2673-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 11/03/2017] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Within China's multi-tiered medical system, many patients seek care in higher-tiered hospitals without a referral by a primary-care provider. This trend, generally referred to as patient self-referral behavior, may reduce the efficiency of the health care system. This study seeks to test the hypothesis that having a usual primary care provider could reduce patients' self-referral behavior. METHODS We obtained medical records of 832 patients who were hospitalized for common respiratory diseases from township hospitals in Qianjiang District of Chongqing City during 2012-2014. Logit regressions were performed to examine the association between having a township hospital as a usual provider and self-referring to a county hospital after being discharged from a township hospital, while controlling for patients' gender, age, income, education, severity of disease, distance to the nearest county hospital and the general quality of the township hospitals in their community. A propensity score weighting approach was applied. RESULTS We found that having a usual primary care provider was associated with a lower likelihood of self-referral (odds ratio = 0.58, 95% confidence interval [CI] =0.41-0.82), and a 9% (95% CI: -14%, - 3%) reduction in the probability of patients' self-referral behavior. DISCUSSION/CONCLUSION The results suggest that establishing a long-term relationship between patients and primary care providers may enhance the patient-physician relationship and reduce patients' tendency for unnecessary use of medical resources.
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Affiliation(s)
- Da Feng
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 of Hangkong Road, Qiaokou District, Wuhan, Hubei Province, China
| | - Donglan Zhang
- Department of Health Policy and Management, College of Public Health, University of Georgia, Athens, GA, USA
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 of Hangkong Road, Qiaokou District, Wuhan, Hubei Province, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 of Hangkong Road, Qiaokou District, Wuhan, Hubei Province, China
| | - Ray Serrano
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Danxiang Shi
- Outpatient Office, Shanghai First Maternity and Infant Hospital, Shanghai, China
| | - Yuan Liu
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No.13 of Hangkong Road, Qiaokou District, Wuhan, Hubei Province, China.
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Harris P, Whitty JA, Kendall E, Ratcliffe J, Wilson A, Littlejohns P, Scuffham PA. The importance of population differences: Influence of individual characteristics on the Australian public's preferences for emergency care. Health Policy 2017; 122:115-125. [PMID: 29157994 DOI: 10.1016/j.healthpol.2017.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 10/25/2017] [Accepted: 11/06/2017] [Indexed: 11/17/2022]
Abstract
A better understanding of the public's preferences and what factors influence them is required if they are to be used to drive decision-making in health. This is particularly the case for service areas undergoing continual reform such as emergency and primary care. Accordingly, this study sought to determine if attitudes, socio-demographic characteristics and healthcare experiences influence the public's intentions to access care and their preferences for hypothetical emergency care alternatives. A discrete choice experiment was used to elicit the preferences of Australian adults (n=1529). Mixed logit regression analyses revealed the influence of a range of individual characteristics on preferences and service uptake choices across three different presenting scenarios. Age was associated with service uptake choices in all contexts, whilst the impact of other sociodemographics, health experience and attitudinal factors varied by context. The improvements in explanatory power observed from including these factors in the models highlight the need to further clarify their influence with larger populations and other presenting contexts, and to identify other determinants of preference heterogeneity. The results suggest social marketing programs undertaken as part of demand management efforts need to be better targeted if decision-makers are seeking to increase community acceptance of emerging service models and alternatives. Other implications for health policy, service planning and research, including for workforce planning and the possible introduction of a system of co-payments are discussed.
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Affiliation(s)
- Paul Harris
- School of Medicine, School of Human Services and Social Work, The Hopkins Centre, Menzies Health Institute of Queensland, Griffith University, Meadowbrook, Queensland 4131, Australia.
| | - Jennifer A Whitty
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
| | - Elizabeth Kendall
- The Hopkins Centre, Menzies Health Institute of Queensland, Griffith University, Meadowbrook, Australia.
| | - Julie Ratcliffe
- Institute for Choice, Business School, University of South Australia, Adelaide, South Australia, Australia.
| | - Andrew Wilson
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, NSW, Australia.
| | - Peter Littlejohns
- Division of Health and Social Care Research, King's College School of Medicine, London, United Kingdom.
| | - Paul A Scuffham
- Menzies Health Institute of Queensland, Griffith University, Logan Campus, Nathan, Queensland, Australia.
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107
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Tammes P, Purdy S, Salisbury C, MacKichan F, Lasserson D, Morris RW. Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England. Ann Fam Med 2017; 15:515-522. [PMID: 29133489 PMCID: PMC5683862 DOI: 10.1370/afm.2136] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/11/2017] [Accepted: 06/05/2017] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Secondary health care services have been under considerable pressure in England as attendance rates increase, resulting in longer waiting times and greater demands on staff. This study's aim was to examine the association between continuity of care and risk of emergency hospital admission among older adults. METHODS We analyzed records from 10,000 patients aged 65 years and older in 2012 within 297 English general practices obtained from the Clinical Practice Research Datalink and linked with Hospital Episode Statistics. We used the Bice and Boxerman (BB) index and the appointed general practitioner index (last general practitioner consulted before hospitalization) to quantify patient-physician continuity. The BB index was used in a prospective cohort approach to assess impact of continuity on risk of admission. Both indices were used in a separate retrospective nested case-control approach to test the effect of changing physician on the odds of hospital admission in the following 30 days. RESULTS In the prospective cohort analysis, the BB index showed a graded, non-significant inverse relationship of continuity of care with risk of emergency hospital admission, although the hazard ratio for patients experiencing least continuity was 2.27 (95% CI, 1.37-3.76) compared with those having complete continuity. In the retrospective nested case-control analysis, we found a graded inverse relationship between continuity of care and emergency hospital admission for both BB and appointed general practitioner indices: for the latter, the odds ratio for those experiencing least continuity was 2.32 (95% CI, 1.48-3.63) relative to those experiencing most continuity. CONCLUSIONS Marked discontinuity of care might contribute to increased unplanned hospital admissions among patients aged 65 years and older. Schemes to enhance continuity of care have the potential to reduce hospital admissions.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sarah Purdy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Fiona MacKichan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Daniel Lasserson
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Department of Gerontology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, Oxford, United Kingdom
| | - Richard W Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Sheaff R, Halliday J, Byng R, Øvretveit J, Exworthy M, Peckham S, Asthana S. Bridging the discursive gap between lay and medical discourse in care coordination. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:1019-1034. [PMID: 28349619 DOI: 10.1111/1467-9566.12553] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients' oral narratives and medical sense-making; and whether a modified form of 'narrative medicine' might mitigate them. We systematically compared 66 general practice patients' own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012-13. Patients' narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients' viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, UK
| | | | - Richard Byng
- School of Medicine and Dentistry, Plymouth University, UK
| | | | - Mark Exworthy
- Health Services Management Centre, University of Birmingham, UK
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Coster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Acad Emerg Med 2017; 24:1137-1149. [PMID: 28493626 PMCID: PMC5599959 DOI: 10.1111/acem.13220] [Citation(s) in RCA: 186] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/31/2017] [Accepted: 04/04/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care. METHODS Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis. RESULTS Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations. CONCLUSIONS We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.
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Affiliation(s)
- Joanne E. Coster
- School for Health and Related Research (ScHARR)University of SheffieldSheffield
| | - Janette K. Turner
- School for Health and Related Research (ScHARR)University of SheffieldSheffield
| | - Daniel Bradbury
- School for Health and Related Research (ScHARR)University of SheffieldSheffield
- Northampton General Hospital NHS TrustNorthamptonUK
| | - Anna Cantrell
- School for Health and Related Research (ScHARR)University of SheffieldSheffield
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110
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Vuik SI, Fontana G, Mayer E, Darzi A. Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation. BMJ Open 2017; 7:e015704. [PMID: 28827243 PMCID: PMC5724125 DOI: 10.1136/bmjopen-2016-015704] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES To explore whether hospitalisations for ambulatory care sensitive conditions (ACSCs) are associated with low access to primary care. DESIGN Observational cohort study over 2008 to 2012 using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. SETTING English primary and secondary care. PARTICIPANTS A random sample of 300 000 patients. MAIN OUTCOME MEASURES Emergency hospitalisation for an ACSC. RESULTS Over the long term, patients with ACSC hospitalisations had on average 2.33 (2.17 to 2.49) more general practice contacts per 6 months than patients with similar conditions who did not require hospitalisation. When accounting for the number of diagnosed ACSCs, age, gender and GP practice through a nested case-control method, the difference was smaller (0.64 contacts), but still significant (p<0.001).In the short-term analysis, measured over the 6 months prior to hospitalisation, patients used more GP services than on average over the 5 years. Cases had significantly (p<0.001) more primary care contacts in the 6 months before ACSC hospitalisations (7.12, 95% CI 6.95 to 7.30) than their controls during the same 6 months (5.57, 95% CI 5.43 to 5.72). The use of GP services increased closer to the time of hospitalisation, with a peak of 1.79 (1.74 to 1.83) contacts in the last 30 days before hospitalisation. CONCLUSIONS This study found no evidence to support the hypothesis that low access to primary care is the main driver of ACSC hospitalisations. Other causes should also be explored to understand how to use ACSC admission rates as quality metrics, and to develop the appropriate interventions.
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Affiliation(s)
- Sabine I Vuik
- Institute of Global Health Innovation, Imperial College, St Mary's Hospital, London, UK
| | - Gianluca Fontana
- Institute of Global Health Innovation, Imperial College, St Mary's Hospital, London, UK
| | - Erik Mayer
- Department of Surgery, Imperial College, St Mary's Hospital, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College, St Mary's Hospital, London, UK
- Department of Surgery, Imperial College, St Mary's Hospital, London, UK
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111
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Tammes P, Morris RW, Brangan E, Checkland K, England H, Huntley A, Lasserson D, MacKichan F, Salisbury C, Wye L, Purdy S. Exploring the relationship between general practice characteristics and attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10-2012/2013: a longitudinal study. BMC Health Serv Res 2017; 17:546. [PMID: 28789652 PMCID: PMC5549356 DOI: 10.1186/s12913-017-2483-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 07/31/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates. METHODS A longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients' emergency attendance rates and patients' reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time. RESULTS Practice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (-0.26 per 1% increase, 95%CI -0.45 to -0.08). CONCLUSION Practices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Richard W Morris
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emer Brangan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Alyson Huntley
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Fiona MacKichan
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
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Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, Chan T, Chew-Graham C, Davies L, de Lusignan S, Dickens C, Drinkwater J, Dunn G, Hunter C, Joy M, Kapur N, Langer S, Lovell K, Macklin J, Mackway-Jones K, Ntais D, Salmon P, Tomenson B, Watson J. CHOICE: Choosing Health Options In Chronic Care Emergencies. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.
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Affiliation(s)
- Elspeth Guthrie
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Cara Afzal
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Greater Manchester Academic Health Science Network (GM AHSN), Manchester, UK
| | - Claire Blakeley
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Amy Blakemore
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel Byford
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Elizabeth Camacho
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Tom Chan
- Department of Health Care Management and Policy, University of Surrey, Guildford, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, UK
| | - Linda Davies
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Simon de Lusignan
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Chris Dickens
- Institute of Health Research, Medical School, University of Exeter, Exeter, UK
- Peninsula Collaboration for Leadership in Health Research and Care (PenCLAHRC), University of Exeter, Exeter, UK
| | | | - Graham Dunn
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Cheryl Hunter
- Health Services Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Mark Joy
- Faculty of Science, Engineering and Computing, Kingston University, London, UK
| | - Navneet Kapur
- Manchester Academic Health Science Centre, Manchester, UK
- Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, UK
| | - Susanne Langer
- Department of Psychology, Manchester Metropolitan University, Manchester, UK
| | - Karina Lovell
- Manchester Academic Health Science Centre, Manchester, UK
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Kevin Mackway-Jones
- Manchester Academic Health Science Centre, Manchester, UK
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Dionysios Ntais
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Health Economics, Institute for Population Health, University of Manchester, Manchester, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Barbara Tomenson
- Manchester Academic Health Science Centre, Manchester, UK
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Jennifer Watson
- Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
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Wolters RJ, Braspenning JCC, Wensing M. Impact of primary care on hospital admission rates for diabetes patients: A systematic review. Diabetes Res Clin Pract 2017; 129:182-196. [PMID: 28544924 DOI: 10.1016/j.diabres.2017.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/02/2017] [Indexed: 11/17/2022]
Abstract
High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.
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Affiliation(s)
- R J Wolters
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands.
| | - J C C Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands.
| | - M Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands; Department of General Practice and Health Services Research Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
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Ismail SA, Pope I, Bloom B, Catalao R, Green E, Longbottom RE, Jansen G, McCoy D, Harris T. Risk factors for admission at three urban emergency departments in England: a cross-sectional analysis of attendances over 1 month. BMJ Open 2017. [PMID: 28645946 PMCID: PMC5541436 DOI: 10.1136/bmjopen-2016-011547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE To investigate factors associated with unscheduled admission following presentation to emergency departments (EDs) at three hospitals in England. DESIGN AND SETTING Cross-sectional analysis of attendance data for patients from three urban EDs in England: a large teaching hospital and major trauma centre (site 1) and two district general hospitals (sites 2 and 3). Variables included patient age, gender, ethnicity, deprivation score, arrival date and time, arrival by ambulance or otherwise, a variety of ED workload measures, inpatient bed occupancy rates and admission outcome. Coding inconsistencies in routine ED data used for this study meant that diagnosis could not be included. OUTCOME MEASURE The primary outcome for the study was unscheduled admission. PARTICIPANTS All adults aged 16 and older attending the three inner London EDs in December 2013. Data on 19 734 unique patient attendances were gathered. RESULTS Outcome data were available for 19 721 attendances (>99%), of whom 6263 (32%) were admitted to hospital. Site 1 was set as the baseline site for analysis of admission risk. Risk of admission was significantly greater at sites 2 and 3 (adjusted OR (AOR) relative to site 1 for site 2 was 1.89, 95% CI 1.74 to 2.05, p<0.001) and for patients of black or black British ethnicity (AOR 1.29, 1.16 to 1.44, p<0.001). Deprivation was strongly associated with admission. Analysis of departmental and hospital-wide workload pressures gave conflicting results, but proximity to the "4-hour target" (a rule that limits patient stays in EDs to 4 hours in the National Health Service in England) emerged as a strong driver for admission in this analysis (AOR 3.61, 95% CI 3.30 to 3.95, p<0.001). CONCLUSION This study found statistically significant variations in odds of admission between hospital sites when adjusting for various patient demographic and presentation factors, suggesting important variations in ED-level and clinician-level behaviour relating to admission decisions. The 4-hour target is a strong driver for emergency admission.
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Affiliation(s)
| | - Ian Pope
- Homerton University Hospital NHS Foundation Trust, London, UK
| | | | | | | | | | | | - David McCoy
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Tim Harris
- Emergency Department, Royal London Hospital, London, UK
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Busby J, Purdy S, Hollingworth W. How do population, general practice and hospital factors influence ambulatory care sensitive admissions: a cross sectional study. BMC FAMILY PRACTICE 2017; 18:67. [PMID: 28545412 PMCID: PMC5445441 DOI: 10.1186/s12875-017-0638-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 05/11/2017] [Indexed: 11/21/2022]
Abstract
Background Reducing unplanned hospital admissions is a key priority within the UK and other healthcare systems, however it remains uncertain how this can be achieved. This paper explores the relationship between unplanned ambulatory care sensitive condition (ACSC) admission rates and population, general practice and hospital characteristics. Additionally, we investigated if these factors had a differential impact across 28 conditions. Methods We used the English Hospital Episode Statistics to calculate the number of unplanned ACSC hospital admissions for 28 conditions at 8,029 general practices during 2011/12. We used multilevel negative binomial regression to estimate the influence of population (deprivation), general practice (size, access, continuity, quality, A&E proximity) and hospital (bed availability, % day cases) characteristics on unplanned admission rates after adjusting for age, sex and chronic disease prevalence. Results Practices in deprived areas (at the 90th centile) had 16% (95% confidence interval: 14 to 18) higher admission rates than those in affluent areas (10th centile). Practices with poorer care continuity (9%; 8 to 11), located closest to A&E (8%; 6 to 9), situated in areas with high inpatient bed availability (14%; 10 to 18) or in areas with a larger proportion of day case admissions (17%; 12 to 21) had more admissions. There were smaller associations for primary care access, clinical quality, and practice size. The strength of associations varied by ACSC. For example, deprivation was most strongly associated with alcohol related diseases and COPD admission rates, while continuity of primary care was most strongly associated with admission rates for chronic diseases such as hypertension and iron-deficiency anaemia. Conclusions The drivers of unplanned ACSC admission rates are complex and include population, practice and hospital factors. The importance of these varies markedly across conditions suggesting that multifaceted interventions are required to avoid hospital admissions and reduce costs. Several of the most important drivers of admissions are largely beyond the control of GPs. However, strategies to improve primary care continuity and avoid unnecessary short-stay admissions could lead to improved efficiency. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0638-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John Busby
- Centre for Public Health, Queen's University Belfast, BT12 6BA, Belfast, UK.
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, BS8 2PS, Bristol, UK
| | - William Hollingworth
- School of Social and Community Medicine, University of Bristol, BS8 2PS, Bristol, UK
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Rosychuk RJ, Rowe BH, McAlister FA. Geographic clustering of emergency department presentations for acute coronary syndromes and heart failure in Alberta: a population-based study. CMAJ Open 2017; 5:E402-E410. [PMID: 28522680 PMCID: PMC5498179 DOI: 10.9778/cmajo.20160155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Collectively, the most common acute cardiac presentations to emergency departments are acute coronary syndromes (ACSs) and heart failure. We examined geographic variation and clustering in emergency department presentations by adults for ACS or heart failure in Alberta in 2010/11. METHODS All emergency department presentations for ACS or heart failure made by Alberta residents aged 35 years or more during 2010/11 were extracted from 5 linked population-based Alberta administrative health databases. Data extracted included demographic characteristics, hospital admissions and physician claims. Spatial scan tests and logistic regression analyses were performed. RESULTS There were 6342 patients with ACS (mean age 65.9 yr, 63.1% male) and 4780 patients with heart failure (mean age 76.6 yr, 49.9% male). For both ACS and heart failure, a primary cluster and 2 secondary clusters were identified. Different clusters were identified for the 2 conditions. For both conditions, patients living in the clusters had more primary care physician claims, prior emergency department visits and prior hospital admissions than did patients living outside the clusters. However, they were less likely to have had a specialist claim in the prior 2 years (odds ratio 0.64 [95% confidence interval 0.56-0.73] for ACS and 0.51 [95% confidence interval 0.43-0.61] for heart failure). INTERPRETATION Geographic areas were identified with higher numbers than expected of patients presenting to the emergency department for ACS or heart failure. Lower specialist access in these areas was associated with increased emergency department use.
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Affiliation(s)
- Rhonda J Rosychuk
- Affiliations: Department of Pediatrics (Rosychuk), University of Alberta; Women & Children's Health Research Institute (Rosychuk); Department of Emergency Medicine (Rowe), University of Alberta; Alberta Health Services (Rowe, McAlister); School of Public Health (Rowe), University of Alberta; Department of Medicine (Rowe, McAlister), University of Alberta, Edmonton, Alta
| | - Brian H Rowe
- Affiliations: Department of Pediatrics (Rosychuk), University of Alberta; Women & Children's Health Research Institute (Rosychuk); Department of Emergency Medicine (Rowe), University of Alberta; Alberta Health Services (Rowe, McAlister); School of Public Health (Rowe), University of Alberta; Department of Medicine (Rowe, McAlister), University of Alberta, Edmonton, Alta
| | - Finlay A McAlister
- Affiliations: Department of Pediatrics (Rosychuk), University of Alberta; Women & Children's Health Research Institute (Rosychuk); Department of Emergency Medicine (Rowe), University of Alberta; Alberta Health Services (Rowe, McAlister); School of Public Health (Rowe), University of Alberta; Department of Medicine (Rowe, McAlister), University of Alberta, Edmonton, Alta
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MacKichan F, Brangan E, Wye L, Checkland K, Lasserson D, Huntley A, Morris R, Tammes P, Salisbury C, Purdy S. Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice. BMJ Open 2017; 7:e013816. [PMID: 28473509 PMCID: PMC5623418 DOI: 10.1136/bmjopen-2016-013816] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). DESIGN Ethnographic case study combining non-participant observation, informal and formal interviewing. SETTING Six general practitioner (GP) practices located in three commissioning organisations in England. PARTICIPANTS AND METHODS Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). RESULTS Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. CONCLUSIONS This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.
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Affiliation(s)
- Fiona MacKichan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emer Brangan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lesley Wye
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Daniel Lasserson
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Alyson Huntley
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard Morris
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Peter Tammes
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Hancock J, Matthews J, Ukoumunne OC, Lang I, Somerfield D, Wenman J, Dickens C. Variation in ambulance call rates for care homes in Torbay, UK. HEALTH & SOCIAL CARE IN THE COMMUNITY 2017; 25:932-937. [PMID: 27578060 DOI: 10.1111/hsc.12381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 06/06/2023]
Abstract
Emergency ambulance calls represent one of the routes of emergency hospital admissions from care homes. We aimed to describe the pattern of ambulance call rates from care homes and identify factors predicting those homes calling for an ambulance most frequently. We obtained data from South Western Ambulance Service NHS Foundation Trust on 3138 ambulance calls relating to people aged 65 and over from care homes in the Torbay region between 1 April 2012 and 31 July 2013. We supplemented this with data from the Care Quality Commission (CQC) website on home characteristics and outcomes of CQC inspections. We used descriptive statistics to identify variation in ambulance call rates for residential and nursing homes and fitted negative binomial regression models to determine if call rates were predicted by home type (nursing versus residential), the five standards in the CQC reports, dementia care status or travel time to hospital. One hundred and forty-six homes (119 residential and 27 nursing) were included in the analysis. The number of calls made ranged from 1 to 99. The median number (IQR; range) of calls per resident per year was 0.51 (0.21-0.89; 0.03-2.45). Nursing homes had a lower call rate than residential homes [adjusted rate ratio (ARR) 0.29; 95% CI: 0.22-0.40; P < 0.001]; care homes failing the quality and suitability of management standard had a lower call rate compared to those who passed (ARR 0.67; 95% CI: 0.50-0.90; P = 0.006); and homes specialising in dementia had a higher call rate compared to those not specialising (ARR 1.56; 95% CI: 1.23-1.96; P < 0.001). These findings require replication in other regions to establish their generalisability and further investigation is required to determine the extent to which call rate variability reflects the different needs of resident populations or differences in care home policies and practice.
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Affiliation(s)
- Jason Hancock
- Mental Health Research Group, University of Exeter Medical School, Exeter, UK
| | - Justin Matthews
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Iain Lang
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | | | - James Wenman
- South Western Ambulance Service NHS Foundation Trust, Exeter, UK
| | - Chris Dickens
- University of Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, Exeter, UK
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada. Soc Sci Med 2017; 181:24-33. [DOI: 10.1016/j.socscimed.2017.03.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 03/02/2017] [Accepted: 03/18/2017] [Indexed: 01/13/2023]
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Atun R, Gurol-Urganci I, Hone T, Pell L, Stokes J, Habicht T, Lukka K, Raaper E, Habicht J. Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data. J Glob Health 2017; 6:020701. [PMID: 27648258 PMCID: PMC5017034 DOI: 10.7189/jogh.06.020701] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Rifat Atun
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ipek Gurol-Urganci
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas Hone
- Department of Primary Care and Public Health, Imperial College, London, UK
| | - Lisa Pell
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Kaija Lukka
- Estonian Health Insurance Fund, Tallinn, Estonia
| | - Elin Raaper
- Estonian Health Insurance Fund, Tallinn, Estonia
| | - Jarno Habicht
- WHO Country Office in Republic of Kyrgyzstan, World Health Organization
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Busby J, Hollingworth W, Purdy S. The role of general practice in reducing unplanned hospital admissions. Br J Hosp Med (Lond) 2017; 78:186-187. [PMID: 28398883 DOI: 10.12968/hmed.2017.78.4.186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- John Busby
- Postdoctoral Research Fellow, Centre for Public Health, Queen's University, Belfast BT12 6BA
| | - William Hollingworth
- Professor of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol
| | - Sarah Purdy
- Professor of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol
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Sheringham J, Solmi F, Ariti C, Baim-Lance A, Morris S, Fulop NJ. The value of theory in programmes to implement clinical guidelines: Insights from a retrospective mixed-methods evaluation of a programme to increase adherence to national guidelines for chronic disease in primary care. PLoS One 2017; 12:e0174086. [PMID: 28328942 PMCID: PMC5362095 DOI: 10.1371/journal.pone.0174086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 03/03/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Programmes have had limited success in improving guideline adherence for chronic disease. Use of theory is recommended but is often absent in programmes conducted in 'real-world' rather than research settings. MATERIALS AND METHODS This mixed-methods study tested a retrospective theory-based approach to evaluate a 'real-world' programme in primary care to improve adherence to national guidelines for chronic obstructive pulmonary disease (COPD). Qualitative data, comprising analysis of documents generated throughout the programme (n>300), in-depth interviews with planners (clinicians, managers and improvement experts involved in devising, planning, and implementing the programme, n = 14) and providers (practice clinicians, n = 14) were used to construct programme theories, experiences of implementation and contextual factors influencing care. Quantitative analyses comprised controlled before-and-after analyses to test 'early' and evolved' programme theories with comparators grounded in each theory. 'Early' theory predicted the programme would reduce emergency hospital admissions (EHA). It was tested using national analysis of standardized borough-level EHA rates between programme and comparator boroughs. 'Evolved' theory predicted practices with higher programme participation would increase guideline adherence and reduce EHA and costs. It was tested using a difference-in-differences analysis with linked primary and secondary care data to compare changes in diagnosis, management, EHA and costs, over time and by programme participation. RESULTS Contrary to programme planners' predictions in 'early' and 'evolved' programme theories, admissions did not change following the programme. However, consistent with 'evolved' theory, higher guideline adoption occurred in practices with greater programme participation. CONCLUSIONS Retrospectively constructing theories based on the ideas of programme planners can enable evaluators to address some limitations encountered when evaluating programmes without a theoretical base. Prospectively articulating theory aided by existing models and mid-range implementation theories may strengthen guideline adoption efforts by prompting planners to scrutinise implementation methods. Benefits of deriving programme theory, with or without the aid of mid-range implementation theories, however, may be limited when the evidence underpinning guidelines is flawed.
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Affiliation(s)
- Jessica Sheringham
- Department of Applied Health Research, University College London, 1–19 Torrington Place, London, United Kingdom
| | - Francesca Solmi
- Department of Applied Health Research, University College London, 1–19 Torrington Place, London, United Kingdom
| | | | - Abigail Baim-Lance
- Department of Applied Health Research, University College London, 1–19 Torrington Place, London, United Kingdom
| | - Steve Morris
- Department of Applied Health Research, University College London, 1–19 Torrington Place, London, United Kingdom
| | - Naomi J. Fulop
- Department of Applied Health Research, University College London, 1–19 Torrington Place, London, United Kingdom
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Maeng DD, Hao J, Bulger JB. Patterns of Multiple Emergency Department Visits: Do Primary Care Physicians Matter? Perm J 2017; 21:16-063. [PMID: 28333606 DOI: 10.7812/tpp/16-063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Overutilization and overreliance on Emergency Departments (EDs) as a usual source of care can lead to unnecessarily high costs and undesirable consequences, such as a gap in care coordination and inadequate provision of preventive care. OBJECTIVE To identify factors associated with multiple ED visits by patients, in particular, the impact of primary care physicians (PCPs) on their patients' multiple ED visit rates. DESIGN Geisinger Health Plan claims data among adult patients who averaged more than 1 ED visit within a 12-month period between 2013 and 2014 were obtained (N = 20,351). MAIN OUTCOME MEASURES Rate of ED visits. Three linear regression models using patient characteristics and utilization patterns as covariates along with PCP fixed effects were estimated to explain the variation in the multiple ED visit rates. RESULTS Multiple ED visits were significantly associated with younger age (18-39 years), having Medicaid insurance, and greater comorbidity. Higher rates of physician office visits and inpatient admissions were also associated with higher rates of multiple ED visits. Accounting for PCP characteristics only marginally improved the explained variation (R2 increased from 0.14 to 0.16). CONCLUSIONS Multiple ED visit patterns are likely driven by patients' health conditions and care needs rather than by their PCPs. Multiple ED visits also appear to be complementary, rather than substitutionary, to PCP visits, suggesting that PCP-focused interventions aimed at reducing ED use are unlikely to have a major impact.
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Affiliation(s)
- Daniel D Maeng
- Primary Investigator and Assistant Professor for the Department of Epidemiology and Health Services Research, Geisinger Health System in Danville, PA.
| | - Jing Hao
- Assistant Professor for the Department of Epidemiology and Health Services Research, Geisinger Health System in Danville, PA.
| | - John B Bulger
- Chief Medical Officer for the Geisinger Health Plan, Geisinger Health System in Danville, PA.
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Massimi A, De Vito C, Brufola I, Corsaro A, Marzuillo C, Migliara G, Rega ML, Ricciardi W, Villari P, Damiani G. Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis. PLoS One 2017; 12:e0173617. [PMID: 28282465 PMCID: PMC5345844 DOI: 10.1371/journal.pone.0173617] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/23/2017] [Indexed: 12/18/2022] Open
Abstract
The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies-3,881 patients) and HbA1c reduction (7 studies-2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01--1.06), DBP -1.42 (95% CI -1.42--0.49) and HbA1c -0.15 (95% CI -0.32-0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive.
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Affiliation(s)
- Azzurra Massimi
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Corrado De Vito
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Ilaria Brufola
- School of Nursing, Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Hygiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alice Corsaro
- Institute of Hygiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carolina Marzuillo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Migliara
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Maria Luisa Rega
- School of Nursing, Università Cattolica del Sacro Cuore, Rome, Italy
- Institute of Hygiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Walter Ricciardi
- Institute of Hygiene, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo Villari
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
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Ruud SE, Hjortdahl P, Natvig B. Reasons for attending a general emergency outpatient clinic versus a regular general practitioner - a survey among immigrant and native walk-in patients in Oslo, Norway. Scand J Prim Health Care 2017; 35:35-45. [PMID: 28277057 PMCID: PMC5361418 DOI: 10.1080/02813432.2017.1288817] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To explore reasons for attending a general emergency outpatient clinic versus a regular general practitioner (RGP). DESIGN Cross-sectional study using a multilingual anonymous questionnaire. SETTING Native and immigrant walk-in patients attending a general emergency outpatient clinic in Oslo (Monday-Friday, 08:00-23:00) during 2 weeks in September 2009. SUBJECTS We included 1022 walk-in patients: 565 native Norwegians (55%) and 457 immigrants (45%). MAIN OUTCOME MEASURES Patients' reasons for attending an emergency outpatient clinic versus their RGP. RESULTS Among patients reporting an RGP affiliation, 49% tried to contact their RGP before this emergency encounter: 44% of native Norwegian and 58% of immigrant respondents. Immigrants from Africa [odds ratio (OR) = 2.55 (95% confidence interval [CI]: 1.46-4.46)] and Asia [OR = 2.32 (95% CI: 1.42-3.78)] were more likely to contact their RGP before attending the general emergency outpatient clinic compared with native Norwegians. The most frequent reason for attending the emergency clinic was difficulty making an immediate appointment with their RGP. A frequent reason for not contacting an RGP was lack of access: 21% of the native Norwegians versus 4% of the immigrants claimed their RGP was in another district/municipality, and 31% of the immigrants reported a lack of affiliation with the RGP scheme. CONCLUSIONS AND IMPLICATIONS Access to primary care provided by an RGP affects patients' use of emergency health care services. To facilitate continuity of health care, policymakers should emphasize initiatives to improve access to primary health care services. KEY POINTS Access to immediate primary health care provided by a regular general practitioner (RGP) can reduce patients' use of emergency health care services. The main reason for attending a general emergency outpatient clinic was difficulty obtaining an immediate appointment with an RGP. A frequent reason for native Norwegians attending a general emergency outpatient clinic during the daytime is having an RGP outside Oslo. Lack of affiliation with the RGP scheme is a frequent reason for attending a general emergency outpatient clinic among immigrants.
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Affiliation(s)
- Sven Eirik Ruud
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway
- CONTACT Sven Eirik Ruud Department of General Practice, Institute of Health and Society, University of Oslo, P.O. Box 1130 Blindern, N-0318 Oslo, Norway
| | - Per Hjortdahl
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Bård Natvig
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Dwyer T, Craswell A, Rossi D, Holzberger D. Evaluation of an aged care nurse practitioner service: quality of care within a residential aged care facility hospital avoidance service. BMC Health Serv Res 2017; 17:33. [PMID: 28086869 PMCID: PMC5237281 DOI: 10.1186/s12913-017-1977-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/04/2017] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Reducing avoidable hospitialisation of aged care facility (ACF) residents can improve the resident experience and their health outcomes. Consequently many variations of hospital avoidance (HA) programs continue to evolve. Nurse practitioners (NP) with expertise in aged care have the potential to make a unique contribution to hospital avoidance programs. However, little attention has been dedicated to service evaluation of this model and the quality of care provided. The purpose of this study was to evaluate the quality of an aged care NP model of care situated within a HA service in a regional area of Australia. METHODS Donabedian's structure, process and outcome framework was applied to evaluate the quality of the NP model of care. The Australian Nurse Practitioner Study standardised interview schedules for evaluating NP models of care guided the semi-structured interviews of nine health professionals (including ACF nurses, medical doctors and allied health professionals), four ACF residents and their families and two NPs. Theory driven coding consistent with the Donabedian framework guided analysis of interview data and presentation of findings. RESULTS Structural dimensions identified included the 'in-reach' nature of the HA service, distance, limitations of professional regulation and the residential care model. These dimensions influenced the process of referring the resident to the NP, the NPs timely response and interactions with other professionals. The processes where the NPs take time connecting with residents, initiating collaborative care plans, up-skilling aged care staff and function as intra and interprofessional boundary spanners all contributed to quality outcomes. Quality outcomes in this study were about timely intervention, HA, timely return home, partnering with residents and family (knowing what they want) and resident and health professional satisfaction. CONCLUSIONS This study provides valuable insights into the contribution of the NP model of care within an aged care, HA service and how staff manipulated the process dimensions to improve referral to the NPs. NP service in this study was dynamic, flexible and responsive to both patient and organisational demands.
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Affiliation(s)
- Trudy Dwyer
- Central Queensland University, Building 18 Rockhampton, Bruce Highway, Rockhampton, Q 4702 Australia
| | - Alison Craswell
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 90 Sippy Downs Drive, Sippy Downs, Q 4556 Australia
| | - Dolene Rossi
- Central Queensland University, Building 18 Rockhampton, Bruce Highway, Rockhampton, Q 4702 Australia
| | - Darren Holzberger
- Central Queensland Hospital and Health Service, Queensland Health, Rockhampton, Q 4770 Australia
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Busby J, Purdy S, Hollingworth W. Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities: an analysis of routine data from England. J Health Serv Res Policy 2016; 22:20-27. [PMID: 27827306 DOI: 10.1177/1355819616666397] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- John Busby
- 1 Currently Postdoctoral Research Fellow, Centre for Public Health, Queen's University Belfast, UK; previously PhD Student, School of Social and Community Medicine, University of Bristol, UK
| | - Sarah Purdy
- 2 Professor of Primary Care, School of Social and Community Medicine, University of Bristol, UK
| | - William Hollingworth
- 3 Professor of Health Economics, School of Social and Community Medicine, University of Bristol, UK
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Opportunities for primary care to reduce hospital admissions: a cross-sectional study of geographical variation. Br J Gen Pract 2016; 67:e20-e28. [PMID: 27777230 DOI: 10.3399/bjgp16x687949] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/07/2016] [Indexed: 12/25/2022] Open
Abstract
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.
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Van den Heede K, Van de Voorde C. Interventions to reduce emergency department utilisation: A review of reviews. Health Policy 2016; 120:1337-1349. [PMID: 27855964 DOI: 10.1016/j.healthpol.2016.10.002] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/30/2016] [Accepted: 10/04/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness. METHODS Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied. RESULTS Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results. CONCLUSION Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.
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Affiliation(s)
- Koen Van den Heede
- Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium.
| | - Carine Van de Voorde
- Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium.
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Khanassov V, Pluye P, Descoteaux S, Haggerty JL, Russell G, Gunn J, Levesque JF. Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review. Int J Equity Health 2016; 15:168. [PMID: 27724952 PMCID: PMC5057425 DOI: 10.1186/s12939-016-0459-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022] Open
Abstract
Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs). SOURCES Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files. STUDY SELECTION One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.
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Affiliation(s)
- Vladimir Khanassov
- Department of Family Medicine, McGill University, 5858 Côte-des-neiges, 3rd Floor, Suite 300, Montreal, QC H3S 1Z1 Canada
| | - Pierre Pluye
- Department of Family Medicine, McGill University, 5858 Côte-des-neiges, 3rd Floor, Suite 300, Montreal, QC H3S 1Z1 Canada
| | - Sarah Descoteaux
- St. Mary’s Hospital Research Centre, 3830 Lacombe Ave, Montréal, QC H3T1M5 Canada
| | - Jeannie L. Haggerty
- Department of Family Medicine, McGill University, St. Mary’s Hospital Research Centre, 3830 Lacombe Ave, Montréal, QC H3T1M5 Canada
| | - Grant Russell
- Southern Academic Primary Care Research Unit, Department of General Practice, School of Primary Health Care, Monash University, Building 1, 270 Ferntree Gully Rd, Notting Hill, VIC 3168 Australia
| | - Jane Gunn
- University of Melbourne, 200 Berkeley Street, Melbourne, VIC 3053 Australia
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales, Bureau of Health Information, 67 Albert Avenue, Chatswood, Sydney, NSW 2067 Australia
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Hayes P, Lynch A, Stiffe J. Moving into the ‘patient-centred medical home’: reforming Australian general practice. EDUCATION FOR PRIMARY CARE 2016; 27:413-415. [DOI: 10.1080/14739879.2016.1218300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sepúlveda MJ, Roebuck MC, Fronstin P, Vidales-Calderon P, Parikh A, Rhee K. Elimination of the Out-of-Pocket Charge for Children's Primary Care Visits: An Application of Value-Based Insurance Design. J Pediatr 2016; 175:195-200. [PMID: 27189683 DOI: 10.1016/j.jpeds.2016.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 03/22/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the impact of a value-based insurance design for primary care among children. STUDY DESIGN A retrospective analysis of health care claims data on 25 950 children (<18 years of age) was conducted. Individuals were enrolled in a large employer's health plans when zero out-of-pocket cost for primary care physician visits was implemented. A rigorous propensity score matching process was used to generate a control group of equal size from a database of other employer-sponsored insurees. Multivariate difference-in-differences models estimated the effect of zero out-of-pocket cost on 21 health services and cost outcomes 24 months after intervention. RESULTS Zero out-of-pocket cost for primary care was associated with significant increases (P < .01) in primary care physician visits (+32 per 100 children), as well as decreases in emergency department (-5 per 100 children) and specialist physician visits (-12 per 100 children). The number of prescription drug fills also declined (-20 per 100 children), yet medication adherence for 3 chronic conditions was unaffected. The receipt of well child visits and 4 recommended vaccinations were all significantly (P < .05) greater under the new plan design feature. Employer costs for primary care increased significantly (P < .01) in association with greater utilization ($29 per child), but specialist visit costs declined (-$12 per child) and total health care costs per child did not exhibit a statistically significant increase. CONCLUSION This novel application of value-based insurance design warrants broader deployment and assessment of its longer term outcomes. As with recommended preventive services, policymakers should consider exempting primary care from health insurance cost-sharing.
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Ruud SE, Hjortdahl P, Natvig B. Is it a matter of urgency? A survey of assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency outpatient clinic in Oslo, Norway. BMC Emerg Med 2016; 16:22. [PMID: 27378228 PMCID: PMC4932670 DOI: 10.1186/s12873-016-0086-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 06/08/2016] [Indexed: 11/16/2022] Open
Abstract
Background Emergency room (ER) use is increasing in several countries. Variability in the proportion of non-urgent ER visits was found to range from 5 to 90 % (median 32 %). Non-urgent emergency visits are considered an inappropriate and inefficient use of the health-care system because they may lead to higher expenses, crowding, treatment delays, and loss of continuity of health care provided by a general practitioner. Urgency levels of doctor–walk-in patient encounters were assessed based on their region of origin in a diverse Norwegian population. Methods An anonymous, multilingual questionnaire was distributed to all walk-in patients at a general emergency outpatient clinic in Oslo during two weeks in September 2009. We analysed demographic data, patient–doctor assessments of the level of urgency, and the results of the consultation. We used descriptive statistics to obtain frequencies with 95 % confidence interval (CI) for assessed levels of urgency and outcomes. Concordance between the patients’ and doctors’ assessments was analysed using a Kendall tau-b test. We used binary logistic regression modelling to quantify associations of explanatory variables and outcomes according to urgency level assessments. Results The analysis included 1821 walk-in patients. Twenty-four per cent of the patients considered their emergency consultation to be non-urgent, while the doctors considered 64 % of encounters to be non-urgent. The concordance between the assessments by the patient and by their doctor was positive but low, with a Kendall tau-b coefficient of 0.202 (p < 0.001). Adjusted logistic regression analysis showed that patients from Eastern Europe (odds ratio (OR) = 3.04; 95 % CI 1.60–5.78), Asia and Turkey (OR = 4.08; 95 % CI 2.43–6.84), and Africa (OR = 8.47; 95 % CI 3.87–18.5) reported significantly higher urgency levels compared with Norwegians. The doctors reported no significant difference in assessment of urgency based on the patient’s region of origin, except for Africans (OR = 0.64; 95 % CI 0.43–0.96). Conclusion This study reveals discrepancies between assessments by walk-in patients and doctors of the urgency level of their encounters at a general emergency clinic. The patients’ self-assessed perception of the urgency level was related to their region of origin. Electronic supplementary material The online version of this article (doi:10.1186/s12873-016-0086-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sven Eirik Ruud
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway. .,Department of Emergency General Practice, City of Oslo Health Agency, Oslo, Norway.
| | - Per Hjortdahl
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Bård Natvig
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Emergency hospital admissions for asthma and access to primary care: cross-sectional analysis. Br J Gen Pract 2016; 66:e640-6. [PMID: 27324628 DOI: 10.3399/bjgp16x686089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 01/27/2016] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Access to general practices may be an important determinant of emergency admissions for asthma, as early treatment of exacerbations has been shown to prevent deterioration. AIM To determine whether access to primary care is associated with emergency admissions for asthma. DESIGN AND SETTING Cross-sectional analysis of data from English practices in 2010-2011. METHOD Negative binomial regression was used to explore the associations between emergency admissions for asthma and seven measures of patient-reported access to general practice services taken from the GP Patient Survey, controlled for the characteristics of practice populations. Incidence rate ratios (IRR) were calculated for each association. RESULTS In total 7806 (95%) of practices had data for all variables. There were 3 134 106 patients with asthma, and there were 55 570 emergency admissions with asthma. Admission rates were lower in practices with a higher composite access score (adjusted IRR for 10% change in variable 0.679, 95% CI = 0.665 to 0.708). Admissions were higher in those practices with higher proportions of the practice population who were white, and in practices with lower performance in the Quality and Outcomes Framework indicator 'asthma review in past 15 months' (Asthma 6). Assuming these associations were causal, a higher access score of 10% was associated with a decrease of 17 837 admissions per year for these practices. CONCLUSION Practices with higher patient-reported access had lower rates of emergency admissions for asthma. Policymakers should consider improving access to primary care as one potential way to help prevent emergency hospital admissions for asthma.
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Tammes P, Morris RW, Brangan E, Checkland K, England H, Huntley A, Lasserson D, MacKichan F, Salisbury C, Wye L, Purdy S. Exploring the relationship between general practice characteristics, and attendance at walk-in centres, minor injuries units and EDs in England 2012/2013: a cross-sectional study. Emerg Med J 2016; 33:702-8. [PMID: 27317586 DOI: 10.1136/emermed-2015-205339] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 05/14/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND For several years, EDs in the UK NHS have faced considerable increases in attendance rates. Walk-in centres (WiCs) and minor injuries units (MIUs) have been suggested as solutions. We aimed to investigate the associations between practice and practice population characteristics with ED attendance rates or combined ED/WiC/MIU attendance, and the associations between WiC/MIU and ED attendance. METHODS We used general practice-level data including 7462 English practices in 2012/2013 and present adjusted regression coefficients from linear multivariable analysis for relationships between patients' emergency attendance rates and practice characteristics. RESULTS Every percentage-point increase in patients reporting inability to make an appointment was associated with an increase in emergency attendance by 0.36 (95% CI 0.06 to 0.66) per 1000 population. Percentage-point increases in patients unable to speak to a general practitioner (GP)/nurse within two workdays and patients able to speak often to their preferred GP were associated with increased emergency attendance/1000 population by 0.23 (95% CI 0.05 to 0.42) and 0.10 (95% CI 0.00 to 0.19), respectively. Practices in areas encompassing several towns (conurbations) had higher attendance than rural practices, as did practices with more non-UK-qualified GPs. Practice population characteristics associated with increased emergency attendance included higher unemployment rates, higher percentage of UK whites and lower male life expectancy, which showed stronger associations than practice characteristics. Furthermore, higher MIU or WiC attendance rates were associated with lower ED attendance rates. CONCLUSIONS Improving availability of appointments and opportunities to speak a GP/nurse at short notice might reduce ED attendance. Establishing MIUs and WiCs might also reduce ED attendance.
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Affiliation(s)
- Peter Tammes
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Richard W Morris
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emer Brangan
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kath Checkland
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Alyson Huntley
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Daniel Lasserson
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Fiona MacKichan
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lesley Wye
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Brainard JS, Ford JA, Steel N, Jones AP. A systematic review of health service interventions to reduce use of unplanned health care in rural areas. J Eval Clin Pract 2016; 22:145-55. [PMID: 26507368 DOI: 10.1111/jep.12470] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2015] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations. METHODS The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively. RESULTS A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions. CONCLUSION Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results.
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Affiliation(s)
| | - John A Ford
- Norwich Medical School, UEA, Norwich, Norfolk, UK
| | | | - Andy P Jones
- Norwich Medical School, UEA, Norwich, Norfolk, UK
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Effect of Named, Accountable GPs on Continuity of Care: Protocol for a Regression Discontinuity Study of a National Policy Change. Int J Integr Care 2016; 16:6. [PMID: 27616950 PMCID: PMC5015538 DOI: 10.5334/ijic.2450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction: Increasing continuity of care has been identified as a
strategy to improve patient outcomes, but previous studies of integrated care
have tended to focus on pilot areas, which limit their generalisability and the
ability to determine in which contexts integrated care was most successful. Objective: This study protocol describes a quantitative evaluation
of a reform in England that introduced named, accountable general practitioners
for all National Health Service (NHS) patients aged 75 years or over. The
national contract for general practice services required that named general
practitioners offer longitudinal continuity of care within the general practice
and be accountable for coordinating care to meet the patient’s healthcare
needs. Methods: This study will apply a regression discontinuity design to
pseudonymised electronic medical records from a sample of general practices in
England. We will compare outcomes for patients aged just below and above the age
of 75 to estimate the effect of named general practitioners and relate these
estimated treatment effects to the characteristics of general practices.
Outcomes will include a metric relating to continuity of care, namely the Usual
Provider of Care Index, and numbers of general practitioner contacts, referrals
to specialist care and diagnostic tests. Discussion: The study illustrates an approach to evaluate national
changes aimed at more integrated care using electronic records, which will
complement in-depth examination in pilot sites.
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Simmonds R, Glogowska M, McLachlan S, Cramer H, Sanders T, Johnson R, Kadam U, Lasserson D, Purdy S. Unplanned admissions and the organisational management of heart failure: a multicentre ethnographic, qualitative study. BMJ Open 2015; 5:e007522. [PMID: 26482765 PMCID: PMC4611875 DOI: 10.1136/bmjopen-2014-007522] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 07/13/2015] [Accepted: 08/17/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Heart failure is a common cause of unplanned hospital admissions but there is little evidence on why, despite evidence-based interventions, admissions occur. This study aimed to identify critical points on patient pathways where risk of admission is increased and identify barriers to the implementation of evidence-based interventions. DESIGN Multicentre, longitudinal, patient-led ethnography. SETTING National Health Service settings across primary, community and secondary care in three geographical locations in England, UK. PARTICIPANTS 31 patients with severe or difficult to manage heart failure followed for up to 11 months; 9 carers; 55 healthcare professionals. RESULTS Fragmentation of healthcare, inequitable provision of services and poor continuity of care presented barriers to interventions for heart failure. Critical points where a reduction in the risk of current or future admission occurred throughout the pathway. At the beginning some patients did not receive a formal clinical diagnosis, in addition patients lacked information about heart failure, self-care and knowing when to seek help. Some clinicians lacked knowledge about diagnosis and management. Misdiagnoses of symptoms and discontinuity of care resulted in unplanned admissions. Approaching end of life, patients were admitted to hospital when other options including palliative care could have been appropriate. CONCLUSIONS Findings illustrate the complexity involved in caring for people with heart failure. Fragmented healthcare and discontinuity of care added complexity and increased the likelihood of suboptimal management and unplanned admissions. Diagnosis and disclosure is a vital first step for the patient in a journey of acceptance and learning to self-care/monitor. The need for clinician education about heart failure and specialist services was acknowledged. Patient education should be seen as an ongoing 'conversation' with trusted clinicians and end-of-life planning should be broached within this context.
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Affiliation(s)
- Rosemary Simmonds
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Margaret Glogowska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Sarah McLachlan
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Helen Cramer
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Tom Sanders
- Section of Public Health, ScHARR, University of Sheffield, Keele, UK
| | - Rachel Johnson
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Umesh Kadam
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
| | - Daniel Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - Sarah Purdy
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Lima VD, Goldberg N, Lourenço L, Chau W, Hogg RS, Guillemi S, Barrios R, Montaner JSG. Virologic suppression and mortality of patients who migrate for HIV care in the province of British Columbia, Canada, from 2003 to 2012: a retrospective cohort study. BMC Health Serv Res 2015; 15:376. [PMID: 26369664 PMCID: PMC4570764 DOI: 10.1186/s12913-015-1042-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 09/04/2015] [Indexed: 01/27/2023] Open
Abstract
Background Migration among persons living with HIV (PLWH) seeking HIV care is common; however its effect on health outcomes in resource-rich settings is not well understood. We conducted a retrospective cohort study to quantify the extent to which PLWH are migrating for care within British Columbia (BC) and its association with virologic suppression and mortality. Methods Eligible PLWH first initiated treatment in BC between 2003 and 2012 (N = 3653). Analyses were performed at the regional Health Authority (HA) level (N = 5). For privacy reasons, we kept the name of these HAs anonymous and we re-named these five regions as 1 to 5. PLWH were classified according to the HA where they resided and received HIV care. We calculated all-cause mortality rates, life expectancies (at age of 20 years), and in, out and net migration rates across HAs using different demographic methods. Virologic suppression (<50 copies/mL) was based on the last viral load available for each PLWH. We also calculated per-capita rates (per 100 PLWH ever on cART) for each HA by dividing the number of PLWH by the number of physicians attending this population. Results There is considerable heterogeneity in physician availability across all HAs, with per-capita rates (per 100 PLWH ever on cART) ranging from 2.2 (HA 1) to 12.7 (HA 3) based on the HA PLWH received care. We observed that in HAs 1, 4, and 5, between 4 and 10 % of PLWH migrated to HA 3 (i.e. the largest urban center) to receive care, and for HA 2 this proportion increased to 21 %. In HA 3, 77 % of its PLWH residents remained in the same HA for their care. Migrating to a larger center for HIV care was not associated with higher rates of viral load suppression; it was significantly associated with lower mortality rates and higher life expectancies. Conclusions A thorough understanding of the reason(s) for these significant migration rates across BC will be critical to inform resource allocation and optimize the impact of HIV treatment.
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Affiliation(s)
- Viviane Dias Lima
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
| | - Nicola Goldberg
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada, M5S 1A8.
| | - Lillian Lourenço
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - William Chau
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Robert S Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada, V5A 1S6.
| | - Silvia Guillemi
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Rolando Barrios
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6.
| | - Julio S G Montaner
- British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6. .,Division of AIDS, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, V6Z 1Y6.
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Busby J, Purdy S, Hollingworth W. 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. BMC Health Serv Res 2015; 15:324. [PMID: 26268576 PMCID: PMC4535775 DOI: 10.1186/s12913-015-0964-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 07/16/2015] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- John Busby
- School of Social and Community Medicine, University of Bristol, Room 2.07, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Sarah Purdy
- Professor of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Professor of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
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O'Cathain A, Knowles E, Turner J, Hirst E, Goodacre S, Nicholl J. Variation in avoidable emergency admissions: multiple case studies of emergency and urgent care systems. J Health Serv Res Policy 2015; 21:5-14. [PMID: 26248621 DOI: 10.1177/1355819615596543] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Alicia O'Cathain
- Professor of Health Services Research, School of Health and Related Research, University of Sheffield, UK
| | - Emma Knowles
- Research Fellow, School of Health and Related Research, University of Sheffield, UK
| | - Janette Turner
- Senior Research Fellow, School of Health and Related Research, University of Sheffield, UK
| | - Enid Hirst
- Chair of Sheffield Emergency Care Forum, Sheffield, UK
| | - Steve Goodacre
- Professor of Emergency Medicine, School of Health and Related Research, University of Sheffield, UK
| | - Jon Nicholl
- Professor of Health Services Research, School of Health and Related Research, University of Sheffield, UK
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Sheaff R, Halliday J, Øvretveit J, Byng R, Exworthy M, Peckham S, Asthana S. Integration and continuity of primary care: polyclinics and alternatives – a patient-centred analysis of how organisation constrains care co-ordination. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03350] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAn ageing population, the increasing specialisation of clinical services and diverse health-care provider ownership make the co-ordination and continuity of complex care increasingly problematic. The way in which the provision of complex health care is co-ordinated produces – or fails to produce – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational and relational). Care co-ordination is accomplished by a combination of activities by patients themselves; provider organisations; care networks co-ordinating the separate provider organisations; and overall health-system governance. This research examines how far organisational integration might promote care co-ordination at the clinical level.ObjectivesTo examine (1) what differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical co-ordination of care; (2) what difference provider ownership (corporate, partnership, public) makes; (3) how much scope either structure allows for managerial discretion and ‘performance’; (4) differences between networked and hierarchical governance regarding the continuity and integration of primary care; and (5) the implications of the above for managerial practice in primary care.MethodsMultiple-methods design combining (1) the assembly of an analytic framework by non-systematic review; (2) a framework analysis of patients’ experiences of the continuities of care; (3) a systematic comparison of organisational case studies made in the same study sites; (4) a cross-country comparison of care co-ordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics; and (5) the analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute inpatient care.ResultsStarting from data about patients’ experiences of the co-ordination or under-co-ordination of care, we identified five care co-ordination mechanisms present in both the integrated organisations and the care networks; four main obstacles to care co-ordination within the integrated organisations, of which two were also present in the care networks; seven main obstacles to care co-ordination that were specific to the care networks; and nine care co-ordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than did care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and a larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care co-ordination because of their impact on general practitioner workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance.ConclusionsOn balance, an integrated organisation seems more likely to favour the development of care co-ordination and, therefore, continuities of care than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings. Future research is therefore required, above all to evaluate comparatively the different techniques for coordinating patient discharge across the triple interface between hospitals, general practices and community health services; and to discover what effects increasing the scale and scope of general practice activities will have on continuity of care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rod Sheaff
- School of Government, Plymouth University, Plymouth, UK
| | | | - John Øvretveit
- Medical Management Centre, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Richard Byng
- Health Services Management Centre, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Exworthy
- Centre for Health Services Studies, University of Birmingham, Birmingham, UK
| | - Stephen Peckham
- Department of Health Services Research and Policy, University of Kent, Kent, UK
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Wilson A, Baker R, Bankart J, Banerjee J, Bhamra R, Conroy S, Kurtev S, Phelps K, Regen E, Rogers S, Waring J. 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. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 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.ObjectivesTo 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.DesignMixed-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’.ParticipantsSix 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.ResultsBetween 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.ConclusionsRising 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 workResearch 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 registrationUK Clinical Reasearch Network 12960.Funding detailsThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Wilson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - John Bankart
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ran Bhamra
- Wolfson School of Mechanical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Simon Conroy
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stoyan Kurtev
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Kay Phelps
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Regen
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Stephen Rogers
- Department of Public Health, NHS Northamptonshire, Northampton, UK
| | - Justin Waring
- Business School, University of Nottingham, Nottingham, UK
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Hazarika R, Purdy S. Integrated care: demonstrating value and valuing patients. Future Hosp J 2015; 2:132-136. [PMID: 31098102 PMCID: PMC6460198 DOI: 10.7861/futurehosp.2-2-132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Integrated care could be seen as an overarching strategy to encourage service change and redesign, rather than solely as a means of cost reduction. Indeed, evidence for the economic benefits of integrated care is equivocal, although many of its components have clear benefits for the quality of services received by patients. Given the financial challenge facing the NHS, integrated care may represent a useful methodology to encourage fundamental service redesign. This level of change is required if the health service is to adapt and survive in the face of significant fiscal challenges.
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146
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Measuring the burden and mortality of hospitalisation in Parkinson's disease: A cross-sectional analysis of the English Hospital Episodes Statistics database 2009–2013. Parkinsonism Relat Disord 2015; 21:449-54. [DOI: 10.1016/j.parkreldis.2015.01.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 01/12/2015] [Accepted: 01/29/2015] [Indexed: 11/19/2022]
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147
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Cecil E, Bottle A, Sharland M, Saxena S. Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions. Ann Fam Med 2015; 13:214-20. [PMID: 25964398 PMCID: PMC4427415 DOI: 10.1370/afm.1786] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions. METHODS We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions. RESULTS There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004. CONCLUSIONS The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
| | - Alex Bottle
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
| | - Mike Sharland
- Paediatric Infectious Disease Unit, St George's Hospital, University of London, United Kingdom
| | - Sonia Saxena
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, United Kingdom
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148
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Abstract
As Cyprus signed a financial agreement with a team of international lenders, several reform measures were outlined as pre-requisites for disbursement of financial instalments. The health sector was massively reformed in order to enhance efficiency and reduce waste. The magnitude of reforms included introduction of guidelines and clinical algorithms, co-payments, and revision of criteria for public beneficiary status. In order to safeguard equity in access, solidarity in coverage and sustainability of its healthcare sector, reforms must continue unabated and, more importantly, the introduction of a universal health system should be the ultimate goal.
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149
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Greenfield G, Ignatowicz AM, Belsi A, Pappas Y, Car J, Majeed A, Harris M. Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study. BMC Health Serv Res 2014; 14:619. [PMID: 25471663 PMCID: PMC4261575 DOI: 10.1186/s12913-014-0619-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 11/19/2014] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Person-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient's world. Patient-centeredness has been commonly defined through physician's behaviors aimed at delivering patient-centered care. Yet, it is unclear how 'person-centeredness' is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context. METHODS We conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison. RESULTS We identified six themes representing core 'ingredients' of person-centeredness in the integrated care context: "Holism", "Naming", "Heed", "Compassion", "Continuity of care", and "Agency and Empowerment", all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt 'unseen' by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional 'Space' to be 'seen' and heard vs. feeling 'translucent', 'unseen', and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a 'dyad', the meanings patients attributed to 'care', and the theoretical correspondence between 'person-centeredness' and 'integrated care'. CONCLUSIONS Person-centeredness is a crucial issue for patients in integrated care, yet it was variably achieved in the current pilot. Patients in the context of integrated care, as in other contexts, strive to have their own unique physical and emotional 'space' to be 'seen' and heard. Integrated care models can benefit from incorporating person-centeredness as a core element.
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