Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates

Exploring variation in ambulance calls and conveyance rates for adults with diabetes mellitus who contact the Northern Ireland Ambulance Service: a retrospective database analysis

Background:

People with diabetes frequently contact the ambulance service about acute problems. Overall, treating diabetes and its associated complications costs the NHS 10% of the annual budget. Reducing unnecessary hospital admissions and ambulance attendances is a high priority policy for the NHS across the UK. This study aimed to determine the characteristics of emergency calls for people with diabetes who contact the ambulance service and are subsequently conveyed to hospital by the Northern Ireland Ambulance Service (NIAS).

Methods:

A retrospective dataset from the NIAS was obtained from the NIAS Trust’s Command and Control system relating to calls where the final complaint group was ‘Diabetes’ for the period 1 January 2017 to 23 November 2019.

Results:

Of a total 11,396 calls related to diabetes, 63.2% of callers to the NIAS were conveyed to hospital. Over half of the calls related to males, with 35.5% of callers aged 60–79. The more deprived areas had a higher frequency of calls and conveyance to hospital, with this decreasing as deprivation decreased. Calls were evenly distributed across the week, with the majority of calls originating outside of GP working hours, although callers were more likely to be conveyed to hospital during working hours. Calls from healthcare professionals were significantly more likely to be conveyed to hospital, despite accounting for the minority of calls.

Conclusion:

This research found that older males were more likely to contact the ambulance service but older females were more likely to be conveyed to hospital. The likelihood of conveyance increased if the call originated from an HCP or occurred during GP working hours. The availability of alternative care pathways has the potential to reduce conveyance to hospital, which has been particularly important during the COVID-19 pandemic. Integration of data is vitally important to produce high quality research and improve policy and practice in this area.

Impact of family physician integrated care program on decreasing utilization of emergency department visit and hospital admission: a population-based retrospective cohort study

BACKGROUND

Hospital admission and emergency department(ED) visits are a massive burden in medical expenditures. In 2003, the Taiwanese government developed Family Physician Integrated Care Program (FPIC) to increase the quality of primary care and decrease medical expenditures. This study's goals were to determine whether FPIC decreased hospital admissions and ED visits and identify the factors influencing the outcomes.

METHODS

This nationwide retrospective cohort study was conducted for the period between 2006 and 2013 by using data obtained from the Taiwan National Health Insurance Research Database. A total of 68,218 individuals were divided into those who joined FPIC and those who did not. We used propensity score matching at a ratio of 1:1 and logistic regression with the generalized estimating equation (GEE) model having a difference-in-difference design to investigate the effects of the FPIC policy on hospital admissions and ED visits in 7 years.

RESULTS

Using logistic regression with the GEE model with the difference-in-difference design, we found no reduction in ED visits and hospital admissions between the two groups. The participants' risk of hospital admissions increased in the first year after joining FPIC (OR: 1.11, 95% CI: 1.03-1.20, P < .05). However, participants who joined FPIC showed an 8% lower risk of hospital admissions in the sixth and seventh years after joining FPIC, compared with those who did not join FPIC (OR: 0.92, 95% CI: 0.85-1.00, P < .05).

CONCLUSIONS

FPIC in Taiwan could not decrease medical utilization initially but might reduce hospital admissions in the long term.

The relationship between individual-level deprivation and health-related quality of life

OBJECTIVE

To examine the association between individual-level deprivation and health-related quality of life (HRQL) in the general population.

METHODS

Data from a population-based survey in the Canadian province of Alberta were used. Individual-level deprivation was assessed using the Canadian Deprivation Index (CDI) and the Ontario Deprivation Index (ODI). HRQL was assessed using the EQ-5D-5 L. Differences in problems in the EQ-5D-5 L dimensions, index and visual analogue scale (VAS) scores across levels of deprivation were examined. Multivariate logistic and linear regression models adjusted for socio-demographic and other characteristics were used to examine the independent association between deprivation and HRQL.

RESULTS

Of the 6314 respondents, 39% were aged between 18 and 44 years and 38% between 45 and 64 years; 60% were female. Mean EQ-5D-5 L index and VAS scores were 0.85 (standard deviation [SD] 0.14) and 79.6 (SD 17.7), respectively. Almost one-third (30.6%) of respondents reported no problems on all EQ-5D-5 L dimensions. Few participants reported some problems with mobility (23.8%), self-care (6.2%) and usual activities (25.2%), while 59.3 and 35.5% reported some levels of pain/discomfort and anxiety/depression, respectively. Differences between the most and least deprived in reporting problems in EQ-5D-5 L dimensions, index and VAS scores were statistically significant and clinically important. In adjusted regression models for both deprivation indices, the least well-off, compared to the most well-off, had higher likelihood of reporting problems in all EQ-5D-5 L dimensions. Compared to the most well-off, the least well-off had an EQ-5D-5 L index score decrement of 0.18 (p < 0.01) and 0.17 (p < 0.01) for the CDI and ODI, respectively. Similarly, an inverse association was found between the VAS score and the CDI (β = - 17.3, p < 0.01) as well as the ODI (β = - 13.3, p < 0.01).

CONCLUSION

Individual-level deprivation is associated with worse HRQL. Poverty reduction strategies should consider the effects of not only neighbourhood-level deprivation, but also that of individual-level deprivation to improve overall health.

Did government spending cuts to social care for older people lead to an increase in emergency hospital admissions? An ecological study, England 2005-2016

OBJECTIVES

Government spending on social care in England reduced substantially in real terms following the economic crisis in 2008, meanwhile emergency admissions to hospitals have increased. We aimed to assess the extent to which reductions in social care spend on older people have led to increases in emergency hospital admissions.

DESIGN

We used negative binomial regression for panel data to assess the relationship between emergency hospital admissions and government spend on social care for older people. We adjusted for population size and for levels of deprivation and health.

SETTING

Hospitals and adult social care services in England between April 2005 and March 2016.

PARTICIPANTS

People aged 65 years and over resident in 132 local councils.

OUTCOME MEASURES

Primary outcome variable-emergency hospital admissions of adults aged 65 years and over. Secondary outcome measure-emergency hospital admissions for ambulatory care sensitive conditions (ACSCs) of adults aged 65 years and over.

RESULTS

We found no significant relationship between the changes in the rate of government spend (£'000 s) on social care for older people within councils and our primary outcome variable, emergency hospital admissions (Incidence rate ratio (IRR) 1.009, 95% CI 0.965 to 1.056) or our secondary outcome measure, admissions for ACSCs (IRR 0.975, 95% CI 0.917 to 1.038).

CONCLUSIONS

We found no evidence to support the view that reductions in government spend on social care since 2008 have led to increases in emergency hospital admissions in older people. Policy makers may wish to review schemes, such as the Better Care Fund, which are predicated on a relationship between social care provision and emergency hospital admissions of older people.

Social gradients in health and social care costs: Analysis of linked electronic health records in Kent, UK

OBJECTIVES

Research into the socio-economic patterning of health and social care costs in the UK has so far been limited to examining only particular aspects of healthcare. In this study, we explore the social gradients in overall healthcare and social care costs, as well as in the disaggregated costs by cost category.

STUDY DESIGN

We calculated the social gradient in health and social care costs by cost category using a linked electronic health record data set for Kent, a county in South East England. We performed a cross-sectional analysis on a sample of 323,401 residents in Kent older than 55 years to assess the impact of neighbourhood deprivation on mean annual per capita costs in 2016/17.

METHODS

Patient-level costs were estimated from activity data for the financial year 2016/17 and were extracted alongside key patient characteristics. Mean costs were calculated for each area deprivation quintile based on the index of multiple deprivation of the neighbourhood (lower super output area) in which the patient lived. Cost subcategories were analysed across primary care, secondary care, social care, community care and mental health.

RESULTS

The mean annual per capita cost increased with deprivation across each deprivation quintile, with a cost of £1205 in the most affluent quintile, compared with £1623 in the most deprived quintile, a 35% cost increase. Social gradients were found across all cost subcategories.

CONCLUSIONS

Health inequalities in the population older than 55 years in Kent are associated with health and social care costs of £109m, equivalent to 15% of the estimated total expenditure in this age group. Such significant costs suggest that appropriate interventions to reduce socio-economic inequalities have the potential to substantially improve population health and, depending on how much investment they require, may even result in cost savings.

Asthma admission rates and patterns of salbutamol and inhaled corticosteroid prescribing in England from 2013 to 2017

Asthma exacerbations are a common reason for hospital admission. We sought to identify whether patterns of inhaler prescribing are significantly associated with regional asthma admission rates. Asthma admission rates were obtained for English Clinical Commissioning Group (CCG) regions from 2013/2014 to 2016/2017. Raw prescribing data were obtained from OpenPrescribing.net, based on monthly general practice-level data published by the National Health Service Business Services Authority. Data were analysed using a linear mixed effects model. The ratio of salbutamol to inhaled corticosteroid prescriptions within a CCG was positively associated with asthma admission rates, independently of median age, asthma prevalence and socioeconomic deprivation.

Hospitalisation after birth of infants: cross sectional analysis of potentially avoidable admissions across England using hospital episode statistics

Background

Admissions of infants in England have increased substantially but there is little evidence whether this is across the first year or predominately in neonates; and for all or for specific causes. We aimed to characterise this increase, especially those admissions that may be avoidable in the context of postnatal care provision.

Methods

A cross sectional analysis of 1,387,677 infants up to age one admitted to English hospitals between April 2008 and April 2014 using Hospital Episode Statistics and live birth denominators for England from Office for National Statistics. Potentially avoidable conditions were defined through a staged process with a panel.

Results

The rate of hospital admission in the first year of life for physiological jaundice, feeding difficulties and gastroenteritis, the three conditions identified as potentially preventable in the context of postnatal care provision, increased by 39% (39.55 to 55.33 per 1000 live births) relative to an overall increase of 6% (334.97 to 354.55 per 1000 live births). Over the first year the biggest increase in admissions occurred in the first 0–6 days (RR 1.26, 95% CI 1.24 to 1.29) and 85% of the increase (12.36 to 18.23 per 1000 live births) in this period was for the three potentially preventable conditions.

Conclusions

Most of the increase in infant hospital admissions was in the early neonatal period, the great majority being accounted for by three potentially avoidable conditions especially jaundice and feeding difficulties. This may indicate missed opportunities within the postnatal care pathway and given the enormous NHS cost and parental distress from hospital admission of infants, requires urgent attention.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1360-z) contains supplementary material, which is available to authorized users.

The expanding burden of idiopathic intracranial hypertension

Objective

To quantify the hospital burden and health economic impact of idiopathic intracranial hypertension.

Methods

Hospital Episode Statistics (HES) national data was extracted between 1st January 2002 and 31st December 2016. All those within England with a diagnosis of idiopathic intracranial hypertension were included. Those with secondary causes of raised intracranial pressure such as tumours, hydrocephalus and cerebral venous sinus thrombosis were excluded.

Results

A total of 23,182 new IIH cases were diagnosed. Fifty-two percent resided in the most socially deprived areas (quintiles 1 and 2). Incidence rose between 2002 and 2016 from 2.3 to 4.7 per 100,000 in the general population. Peak incidence occurred in females aged 25 (15.2 per 100,000). 91.6% were treated medically, 7.6% had a cerebrospinal fluid diversion procedure, 0.7% underwent bariatric surgery and 0.1% had optic nerve sheath fenestration. Elective caesarean sections rates were significantly higher in IIH (16%) compared to the general population (9%), p < 0.005. Admission rates rose by 442% between 2002 and 2014, with 38% having repeated admissions in the year following diagnosis. Duration of hospital admission was 2.7 days (8.8 days for those having CSF diversion procedures). Costs rose from £9.2 to £50 million per annum over the study period with costs forecasts of £462 million per annum by 2030.

Conclusions

IIH incidence is rising (by greater than 100% over the study), highest in areas of social deprivation and mirroring obesity trends. Re-admissions rates are high and growing yearly. The escalating population and financial burden of IIH has wide reaching implications for the health care system.

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

OBJECTIVES

To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London.

DESIGN

Cross sectional analysis at primary care trusts level using routine data from multiple sources.

SETTING

All 31 primary care trusts in London with a total resident population of 7 million patients.

MAIN OUTCOME MEASURES

Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease.

RESULTS

Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100,000 and for diabetes from 38 to 183 per 100,000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined.

CONCLUSIONS

Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.

Impact of regional socioeconomic variation on coordination and cost of ambulatory care: investigation of claims data from Bavaria, Germany

OBJECTIVES

A considerable proportion of regional variation in healthcare use and health expenditures is to date still unexplained. The aim was to investigate regional differences in the gatekeeping role of general practitioners and to identify relevant explanatory variables at patient and district level in Bavaria, Germany.

DESIGN

Retrospective routine data analysis using claims data held by the Bavarian Association of Statutory Health Insurance Physicians.

PARTICIPANTS

All patients who consulted a specialist in ambulatory practice within the first quarter of 2011 (n=3 616 510).

OUTCOMES MEASURES

Of primary interest is the effect of district-level measures of rurality, physician density and multiple deprivation on (1) the proportion of patients with general practitioner (GP) coordination of specialist care and (2) the mean amount in Euros claimed by specialist physicians.

RESULTS

The proportion of patients whose use of specialist services was coordinated by a GP was significantly higher in rural areas and in highly deprived regions, as compared with urban and less deprived regions. The hierarchical models revealed that increasing age and the presence of chronic diseases are the strongest predictive factors for coordination by a GP. In contrast, the presence of mental illness, an increasing number of medical condition categories and living in a city are predictors for specialist use without GP coordination. The amount claimed per patient was €10 to €20 higher in urban districts and in regions with lower deprivation. Hierarchical models indicate that this amount is on average higher for patients living in towns and lower for patients in regions with high deprivation.

CONCLUSION

The present study shows that regional deprivation is closely associated with the way in which patients access primary and specialist care. This has clear consequences, both with respect to the role of the general practitioner and the financial costs of care.

Impact of primary care on hospital admission rates for diabetes patients: A systematic review

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.

People with epilepsy obtain added value from education in groups: results of a qualitative study

Background and purpose

Having epilepsy requires individuals to learn about self‐management. So far, trials of self‐management courses have not included in‐depth qualitative evaluations of how the learning method influences participants’ perceptions and behaviour. We aimed to interview participants who had attended a course, as part of a randomized controlled trial, to examine: (i) their perceptions of what they valued and negative aspects of the intervention, and (ii) whether and in what ways they continued to make use of the training.

Methods

Twenty participants were selected within 6 months of undertaking a course from the larger randomized controlled trial conducted in England. Semi‐structured interviews were based on a topic guide.

Results

Participants’ characteristics were representative of the clinical and demographic characteristics of the trial group. Their mean age was 44 years, half were male, and three‐quarters had had epilepsy for over 10 years and had experienced one or more seizures in the previous month. Participants valued the opportunity to meet ‘people like them’. Structured learning methods encouraged them to share and compare feelings and experience. Specific benefits included: overcoming the sense of ‘being alone’ and improving self‐acceptance through meeting people with similar experience. Over half reported that this, and comparison of attitudes and experience, helped them to improve their confidence to talk openly, and make changes in health behaviours.

Conclusions

People feel socially isolated in long‐term poorly controlled epilepsy. They gain confidence and self‐acceptance from interactive groups. Expert‐facilitated courses that encourage experiential learning can help people learn from each other, and this may enhance self‐efficacy and behaviour change.

Socioeconomic deprivation and accident and emergency attendances: cross-sectional analysis of general practices in England

BACKGROUND

Demand for England's accident and emergency (A&E) services is increasing and is particularly concentrated in areas of high deprivation. The extent to which primary care services, relative to population characteristics, can impact on A&E is not fully understood.

AIM

To conduct a detailed analysis to identify population and primary care characteristics associated with A&E attendance rates, particularly those that may be amenable to change by primary care services.

DESIGN AND SETTING

This study used a cross-sectional population-based design. The setting was general practices in England, in the year 2011-2012.

METHOD

Multivariate linear regression analysis was used to create a model to explain the variability in practice A&E attendance rates. Predictor variables included population demographics, practice characteristics, and measures of patient experiences of primary care.

RESULTS

The strongest predictor of general practice A&E attendance rates was social deprivation: the Index of Multiple Deprivation (IMD-2010) (β = 0.3. B = 1.4 [95% CI =1.3 to 1.6]), followed by population morbidity (GPPS responders reporting a long-standing health condition) (β = 0.2, B = 231.5 [95% CI = 202.1 to 260.8]), and knowledge of how to contact an out-of-hours GP (GPPS question 36) (β = -0.2, B = -128.7 [95% CI =149.3 to -108.2]). Other significant predictors included the practice list size (β = -0.1, B = -0.002 [95% CI = -0.003 to -0.002]) and the proportion of patients aged 0-4 years (β = 0.1, B = 547.3 [95% CI = 418.6 to 676.0]). The final model explained 34.4% of the variation in A&E attendance rates, mostly due to factors that could not be modified by primary care services.

CONCLUSION

Demographic characteristics were the strongest predictors of A&E attendance rates. Primary care variables that may be amenable to change only made a small contribution to higher A&E attendance rates.

Influence of social deprivation, overcrowding and family structure on emergency medical admission rates

BACKGROUND

Patients from deprived backgrounds have a higher in-patient mortality following emergency medical admission.

AIM

To evaluate the influence of Deprivation Index, overcrowding and family structure on hospital admission rates.

DESIGN

Retrospective cohort study.

METHODS

All emergency medical admissions from 2002 to 2013 were evaluated. Based on address, each patient was allocated to an electoral division, whose small area population statistics were available from census data. Patients were categorized by quintile of Deprivation Index, overcrowding and family structure, and these were evaluated against hospital admission rate, calculated as rate/1000 population. Univariate and multivariable risk estimates (Odds Ratios or Incidence Rate Ratios) were calculated, using logistic or zero truncated Poisson regression as appropriate.

RESULTS

There were 66 861 admissions in 36 214 patients over the 12-year study period. Deprivation Index quintile independently predicted the admission rate, with rates of Q1 12.0 (95% CI 11.8-12.2), Q2 19.5 (95% CI 19.3-19.6), Q3 33.7 (95% CI 33.3-34.0), Q4 31.4 (95% CI 31.2-31.6) and Q5 38.1 (95% CI 37.7-38.5). Similarly the proportions of families with children <15 years old, was an independent predictor of the admission rate with rates of Q1 20.8 (95% CI 20.4-21.1), Q2 23.0 (95% CI 22.7-23.3), Q3 32.2 (95% CI 31.9-32.5), Q4 32.4 (95% CI 32.2-32.7) and Q5 37.2 (95% CI 36.6-37.8). The proportion of families with children ≥15-years old was also predictive but quintile of overcrowding was only predictive in the univarate model.

CONCLUSION

Deprivation Index and family structure strongly predict emergency medical hospital admission rates.

Effect of a national requirement to introduce named accountable general practitioners for patients aged 75 or older in England: regression discontinuity analysis of general practice utilisation and continuity of care

OBJECTIVE

To assess the effect of introducing named accountable general practitioners (GPs) for patients aged 75 years on patterns of general practice utilisation, including continuity of care.

DESIGN

Regression discontinuity design applied to data from the Clinical Practice Research Datalink to estimate the treatment effect for compliers aged 75.

SETTING

200 general practices in England.

PARTICIPANTS

255 469 patients aged between 65 and 85, after excluding those aged 75.

INTERVENTION

From April 2014, general practices in England were required to offer patients aged 75 or over a named accountable GP. This study compared having named accountable GPs for patients aged just over 75 with usual care provided for patients just under 75.

OUTCOMES

Number of contacts (face-to-face or telephone) with GPs, longitudinal continuity of care (usual provider of care, or UPC, index), number of referrals to specialist care and numbers of common diagnostic tests. Outcomes were measured over 9 months following assignment to a named accountable GP and for a comparable period for those unassigned.

RESULTS

The proportion of patients with a named accountable GP increased from 3.5% to 79.8% at age 75. No statistically significant effects were detected for continuity of care (estimated treatment effect 0.00, 95% CI -0.01 to 0.02) or the number of GP contacts per person (estimated treatment effect -0.11, 95% CI -0.31 to 0.09) over 9 months. No significant change was seen in the number of referrals, blood pressure or HbA1c diagnostic tests per person. A statistically significant treatment effect of -0.05 cholesterol tests per person (95% CI -0.07 to -0.02) was estimated; however, sensitivity analysis indicated that this effect predated the introduction of named accountable GPs.

CONCLUSIONS

Continuity of care is valued by patients, but the named accountable GP initiative did not improve continuity of care or change patterns of GP utilisation in the first 9 months of the policy.

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

OBJECTIVE

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Deprivation index and dependency ratio are key determinants of emergency medical admission rates

BACKGROUND

Patients from deprived backgrounds have a higher in-patient mortality following an emergency medical admission; there has been debate as to the extent to which deprivation and population structure influences hospital admission rate.

METHODS

All emergency medical admissions to an Irish hospital over a 12-year period (2002-2013) categorized by quintile of Deprivation Index and Dependency Ratio (proportion of population <15 or ≥ 65 years) from small area population statistics (SAPS), were evaluated against hospital admission rates. Univariate and multivariable risk estimates (Odds Ratios (OR) or Incidence Rate Ratios (IRR)) were calculated, using logistic or zero truncated Poisson regression as appropriate.

RESULTS

66,861 admissions in 36,214 patients occured during the study period. The Deprivation Index quintile independently predicted the admission rate/1000 population, Q1 9.4 (95%CI 9.2 to 9.7), Q2 16.8 (95%CI 16.6 to 17.0), Q3 33.8 (95%CI 33.5 to 34.1), Q4 29.6 (95%CI 29.3 to 29.8) and Q5 45.4 (95%CI 44.5 to 46.2). Similarly the population Dependency Ratio was an independent predictor of the admission rate with adjusted predicted rates of Q1 20.8 (95%CI 20.5 to 21.1), Q2 19.2 (95%CI 19.0 to 19.4), Q3 27.6 (95%CI 27.3 to 27.9), Q4 43.9 (95%CI 43.5 to 44.4) and Q5 34.4 (95%CI 34.1 to 34.7). A high concurrent Deprivation Index and Dependency Ratio were associated with very high admission rates.

CONCLUSION

Deprivation Index and population Dependency Ratio are key determinants of the rate of emergency medical admissions.

The relationship between depressive symptoms, diabetes symptoms, and self-management among an urban, low-income Latino population

OBJECTIVE

To investigate the prevalence of depression symptoms among Latinos with diabetes following transition from hospital to home and the relationship of depressive symptoms to diabetes symptom severity and self-management activities.

METHODS

203 Latino patients with diagnosed diabetes completed a survey assessing depressive symptoms (PHQ-9), diabetes symptom severity, and diabetes self-management activities (SDSCA). Characteristics and diabetes outcomes between patients with and without probable major depression were compared. Associations between PHQ-9 scores and diabetes outcomes were assessed. Multivariate regression models evaluated the relationship between depressive symptoms and diabetes outcomes and exercise after controlling for patient characteristics.

RESULTS

31.5% of participants indicated probable major depression (PHQ-9≥10). More severe diabetes symptoms and less reported exercise were associated with higher PHQ-9 scores. Regression models showed no relationship between self-management and depression. More severe diabetes symptoms were significantly associated with being female, married, and having probable major depression. Odds of exercising were reduced by 6% for every one-unit increase in PHQ-9 score.

CONCLUSIONS

The prevalence of probable depressive symptoms is high in this population. Having depressive symptoms is an indicator of poorer diabetes symptoms. Screening for depressive symptoms may help identify individuals who need additional support with diabetes symptom and self-management.

Non elective re-admissions to an acute hospital in people with diabetes: Causes and the potential for avoidance. The WICKED project

INTRODUCTION

Managing people with diabetes is a health priority worldwide. Cost benefit attempts at avoiding non elective admissions (NEA) have had some success. To develop an NEA avoidance service, we audited multiple NEA in those with diabetes.

METHOD

All people with diabetes who had ≥3 NEA to our hospital over 12 months were identified (n=418); 104 (1 in 4) patients were randomly selected and retrospective data collected in 98 subjects on their index (latest, 3rd) admission.

RESULTS

Of 98 subjects (50 males, 60 Caucasians, 86 type 2 diabetes, aged 69±16 years).Conditions contributing to admission included: Significant co-morbidities in 95 patients (≥2 in 57, ≥4 in 24). Only 14 admission were directly due to diabetes: hypoglycaemia (5); hyperglycaemia (6); DKA (2), Infected foot ulcer (1).97 admissions were justified at the time of presentation. However whilst 78 were unavoidable, 19 were deemed avoidable amongst whom 10 were diabetes related.

CONCLUSION

The majority of re-admissions were due to multi-morbidity and were often non-diabetes related. The concept of avoidability must be distinguished from point justification at the time of acute need. This would allow the prospective identification of high risk patients and requires an integrated working process to avoid NEA.

Inequality in diabetes-related hospital admissions in England by socioeconomic deprivation and ethnicity: facility-based cross-sectional analysis

Objective

To investigate the effect of social deprivation and ethnicity on inpatient admissions due to diabetes in England.

Design

Facility-based cross-sectional analysis.

Setting

National Health Service (NHS) trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010–2011 (355 facilities).

Participants

Non-obstetric patients over 16 years old in all NHS facilities in England. The sample size after exclusions was 5,147,859 all-cause admissions.

Main Outcome Measures

The relative risk of inpatient admissions and readmissions due to diabetes adjusted for confounders.

Results

There were 445,504 diabetes-related hospital admissions in England in 2010, giving a directly (age-sex) standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0–1052.1). The relative risk of inpatient admission in the most deprived quintile was 2.08 times higher than that of the least deprived quintile (95% CI: 2.02–2.14), and the effect of deprivation varied across ethnicities. About 30.1% of patients admitted due to diabetes were readmitted at least once due to diabetes. South Asians showed 2.62 times (95% CI: 2.51 – 2.74) higher admission risk. Readmission risk increased with IMD among white British but not other ethnicities. South Asians showed slightly lower risk of readmission than white British (0.86, 95% CI: 0.80 – 0.94).

Conclusions

More deprived areas had higher rates of inpatient admissions and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher rates of admission among deprived people may not necessarily reflect higher prevalence, but higher admission rates in south Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in primary care to prevent readmission. Better interventions in poorer areas, are needed to reduce these inequalities.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Funding

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

Which features of primary care affect unscheduled secondary care use? A systematic review

OBJECTIVES

To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care.

SETTING

Observational studies at primary care practice level.

PARTICIPANTS

Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions.

RESULTS

48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed.

CONCLUSIONS

The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions.

Hospital characteristics affecting potentially avoidable emergency admissions: national ecological study

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

Can an epilepsy nurse specialist-led self-management intervention reduce attendance at emergency departments and promote well-being for people with severe epilepsy? A non-randomised trial with a nested qualitative phase

Objectives

To (1) describe the characteristics and service use of people with established epilepsy (PWE) who attend the emergency department (ED); (2) evaluate the economic impact of PWE who attend the ED; (3) determine the effectiveness and cost-effectiveness of an epilepsy nurse specialist (ENS)-led self-management intervention plus treatment as usual (TAU) compared with TAU alone in reducing ED use and promoting well-being; (4) describe patients' views of the intervention; and (5) explore their reasons for attending the ED.

Design

Non-randomised trial with nested qualitative study.

Setting

The EDs of three inner London hospitals. The EDs each offer similar services and support a similar local population, which made a comparison of patient outcomes reasonable.

Participants

Adults diagnosed with epilepsy for ≥ 1 year were prospectively identified from the EDs by presenting symptom/discharge diagnosis. We recruited 85 of 315 patients with 44 forming the intervention group and 41 the comparison group.

Intervention

Intervention participants were offered two one-to-one outpatient sessions delivered by an ENS who aimed to optimise self-management skills and knowledge of appropriate emergency service use. The first session lasted for 45–60 minutes and the second for 30 minutes.

Main outcome measures

The primary outcome was the number of ED visits that participants reported making over the 6 months preceding the 12-month follow-up. Secondary outcomes were visits reported at the 6-month follow-up and scores on psychosocial measures.

Results

In the year preceding recruitment, the 85 participants together made 270 ED visits. The frequency of their visits was positively skewed, with 61% having attended multiple times. The mean number of visits per participant was 3.1 [standard deviation (SD) 3.6] and the median was two (interquartile range 1–4). Mean patient service cost was £2355 (SD £2455). Compared with findings in the general epilepsy population, participants experienced more seizures and had greater anxiety, lower epilepsy knowledge and greater perceived stigma. Their outpatient care was, however, consistent with National Institute for Health and Clinical Excellence recommendations. In total, 81% of participants were retained at the 6- and 12-month follow-ups, and 80% of participants offered the intervention attended. Using intention-to-treat analyses, including those adjusted for baseline differences, we found no significant effect of the intervention on ED use at the 6-month follow-up [adjusted incidence rate ratio (IRR) 1.75, 95% confidence interval (CI) 0.93 to 3.28] or the 12-month follow-up (adjusted IRR 1.92, 95% CI 0.68 to 5.41), nor on any psychosocial outcomes. Because they spent less time as inpatients, however, the average service cost of intervention participants over follow-up was less than that of TAU participants (adjusted difference £558, 95% CI –£2409 to £648). Lower confidence in managing epilepsy and more felt stigma at baseline best predicted more ED visits over follow-up. Interviews revealed that patients generally attended because they had no family, friend or colleague nearby who had the confidence to manage a seizure. Most participants receiving the intervention valued it, including being given information on epilepsy and an opportunity to talk about their feelings. Those reporting most ED use at baseline perceived the most benefit.

Conclusions

At baseline, > 60% of participants who had attended an ED in the previous year had reattended in the same year. In total, 50% of their health service costs were accounted for by ED use and admissions. Low confidence in their ability to manage their epilepsy and a greater sense of stigma predicted frequent attendance. The intervention did not lead to a reduction in ED use but did not cost more, partly because those receiving the intervention had shorter average hospital stays. The most common reason reported by PWE for attending an ED was the lack of someone nearby with sufficient experience of managing a seizure. Those who attended an ED frequently and received the intervention were more likely to report that the intervention helped them. Our findings on predictors of ED use clarify what causes ED use and suggest that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency savings generated.

Trial registration

Current Controlled Trials ISRCTN06469947.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 1, No. 9. See the HSDR programme website for further project information.

Impact of deprivation on occurrence, outcomes and health care costs of people with multiple morbidity

Objective

This study aimed to estimate the impact of deprivation on the occurrence, health outcomes and health care costs of people with multiple morbidity in England.

Methods

Cohort study in the UK Clinical Practice Research Datalink, using deprivation quintile (IMD2010) at individual postcode level. Incidence and mortality from diabetes mellitus, coronary heart disease, stroke and colorectal cancer, and prevalence of depression, were used to define multidisease states. Costs of health care use were estimated for each state from a two-part model.

Results

Data were analysed for 141,535 men and 141,352 women aged ≥30 years, with 33,862 disease incidence events, and 13,933 deaths. Among incidences of single conditions, 22% were in the most deprived quintile and 19% in the least deprived; dual conditions, most deprived 26%, least deprived 16% and triple conditions, most deprived 29%, least deprived 14%. Deaths in participants without disease were distributed most deprived 22%, least deprived 19%; in participants with single conditions, most deprived 24%, least deprived 18%; dual conditions, most deprived 27%, least deprived 15%, and triple conditions, most deprived 33%, least deprived 17%. The relative rate of depression in most deprived participants with triple conditions, compared with least deprived and no disease, was 2.48 (1.74 to 3.54). Costs of health care use were associated with increasing deprivation and level of morbidity.

Conclusions

The higher incidence of disease, associated with deprivation, channels deprived populations into categories of multiple morbidity with a greater prevalence of depression, higher mortality and higher costs. This has implications for the way that resources are allocated in England’s National Health Service.

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study

Background

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care.

Aim

To identify system-wide factors explaining variation in age sex adjusted admission rates for conditions rich in avoidable admissions.

Design

National ecological study.

Setting

152 emergency and urgent care systems in England.

Methods

Hospital Episode Statistics data on emergency admissions were used to calculate an age sex adjusted admission rate for conditions rich in avoidable admissions for each emergency and urgent care system in England for 2008–2011.

Results

There were 3 273 395 relevant admissions in 2008–2011, accounting for 22% of all emergency admissions. The mean age sex adjusted admission rate was 2258 per year per 100 000 population, with a 3.4-fold variation between systems (1268 and 4359). Factors beyond the control of health services explained the majority of variation: unemployment rates explained 72%, with urban/rural status explaining further variation (R²=75%). Factors related to emergency departments, hospitals, emergency ambulance services and general practice explained further variation (R²=85%): the attendance rate at emergency departments, percentage of emergency department attendances converted to admissions, percentage of emergency admissions staying less than a day, percentage of emergency ambulance calls not transported to hospital and perceived access to general practice within 48 h.

Conclusions

Interventions to reduce avoidable admissions should be targeted at deprived communities. Better use of emergency departments, ambulance services and primary care could further reduce avoidable emergency admissions.

Explanations given by people with epilepsy for using emergency medical services: a qualitative study

Half of the people with epilepsy (PWE) in the UK experience seizures and 13-18% attend emergency medical services (EMS) annually. The majority of attendances are regarded as clinically unjustified. This study describes PWE explanations for using EMS. A nested qualitative study, part of a larger study based in three South London hospitals, was conducted. Semi-structured interviews were recorded, transcribed, and analyzed thematically. A seizure alone was not the main explanation for attending EMS; knowledge, experience, and confidence of those nearby on what to do and seizure context were important. Additionally, fears of sudden death held by the PWE and others were reported. From the patients' perspective, use of EMS is regarded as appropriate when they are away from home or someone nearby lacks knowledge of seizure management. Hospitals could provide regular group sessions on seizure management for PWE and their significant others, in which fears are discussed and evaluated.

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

BACKGROUND

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

AIM

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

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Emergency respiratory admissions: influence of practice, population and hospital factors

OBJECTIVE

To determine the influence of population, hospital and general practice characteristics on practice admission rates for asthma and chronic obstructive pulmonary disease (COPD) in England.

METHODS

Cross sectional study using Hospital Episode Statistics (HES), routine population data and primary care data. Admissions for all general practices in England during 2005-06, adjusted for age and sex composition of practice population. Univariable analysis of population, practice and hospital care provision variables, including prevalence and quality data. Significant factors included in multiple regression Poisson model.

RESULTS

Admissions from 8169 practices were included. Risk of admission for each condition increased with deprivation, prevalence and smoking. Admission rates were higher in urban than rural practices. Hospital bed availability and distance to the nearest emergency department were also significantly associated with risk of admission. The associations with practice factors including practice size and quality markers varied across conditions.

CONCLUSIONS

Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates.

Social economic inequalities and mental health II. Methodological aspects and literature review

Summary

Objective - This study provides a framework for mental health inequalities beginners. It describes the methods used to measure socio economic inequalities and the inter-relations with different aspects of mental health: residence, mental health services organisation and main diagnostic categories. Method - Literature electronic-search on Medline, Psyclit, Econlit, Social Science Index and SocioSearch usingand relating the key-words inequalities, deprivation, poverty, socio-economic status, social class, occupational class, mental health for the period 1965-2002 (June). The articles selected were integrated with manual search (publications of the same authors, cross-references, working documents and reports of international andregional organisations). Results - Inequality is not an absolute concept and, mainly, it has been changing during the last years. For example, the integration and re-definition of variables that capture, in simple indices, a complex reality; the accent on social more than on economic aspects; the geo-validity and time-reference of the inequality's indices. Moreover, the inequalities could be the result of individual preferences, in this case, the social selectionand social causation issues will raise the suitability for a public intervention. Conclusions - Up to now, research has been mainly concentrated in describing and measuring health inequalities. For designing effective interventions, policy makers need to ground decisions on health-socioeconomic inequalities explanatory models.

Declaration of Interest

this work was partly funded by the Department of the Public Health Sciences “G. Sanarelli” of the University of Rome “La Sapienza” and the Department of Medicine and Public Health of the University of Verona.

Epilepsy mortality and risk factors for death in epilepsy: a population-based study

BACKGROUND

Epilepsy is an important cause of amenable mortality but risk factors for death in epilepsy are not well understood.

AIM

To evaluate trends in epilepsy mortality in a large population and identify risk factors for death in epilepsy.

DESIGN AND SETTING

Nested case-control study in the UK, using data from the General Practice Research Database (GPRD) from 1993 to 2007.

METHOD

Participants were included if they had ever been diagnosed with epilepsy and prescribed anticonvulsant drugs. Trends in all-cause mortality in persons with epilepsy in the GPRD were compared with death registrations with epilepsy as the underlying cause. A nested case-control study was implemented to compare participants with epilepsy who died with those who did not die.

RESULTS

The prevalence of epilepsy increased from 9 per 1000 in 1993 to 12 per 1000 in 2007, and epilepsy deaths also increased in this period. In a nested case-control study, mortality was associated with: recorded alcohol problems (odds ratio [OR] 2.96, 95% confidence interval [CI] = 2.25 to 3.89, P<0.001); having collected the last anticonvulsant prescription 90-182 days previously (OR 1.83, CI = 1.66 to 2.03, P<0.001); having an injury in the previous year (OR 1.41, 95% CI = 1.30 to 1.53, P<0.001), and having been treated for depression (OR 1.39, 95% CI = 1.28 to 1.50, P<0.001). In data available from 2004 onwards, being recorded seizure free in the previous 12 months was associated with lower mortality (OR 0.78, 95% CI = 0.71 to 0.86, P<0.001).

CONCLUSION

Mortality with epilepsy appears to be increasing. Patients who have alcohol problems, do not collect repeat prescriptions for anticonvulsant drugs, have recent injuries, or have been treated for depression may be at increased risk of death; patients who remain seizure free over 12 months are at a lower risk.

The prevalence of Type 2 diabetes and its associated health problems in a community-dwelling elderly population

AIMS

Prevalence estimates of Type 2 diabetes and its associated health problems in elderly populations are rare, especially in the very elderly.

METHODS

A sample of 15 095 community-dwelling older people aged > or = 75 years were assessed. Type 2 diabetes and associated health problems were identified using self-reporting, general practitioner records, drug histories, and blood and urine measurements.

RESULTS

There were 1177 people identified as having Type 2 diabetes mellitus, giving an overall prevalence of 7.8% (95% confidence interval 7.1, 8.5), 9.4% (8.4, 10.5) for men and 6.8% (6.1, 7.6) for women. The age, sex and smoking adjusted odds ratios for various health problems, comparing people with and without diabetes were: low vision 1.6 (1.3, 1.9), proteinuria 1.7 (1.4, 2.1), chronic kidney disease stage 4 or 5 1.5 (1.0, 2.1), angina 1.3 (1.1, 1.6), myocardial infarction 1.5 (1.2, 1.8), cerebrovascular event 2.0 (1.8, 2.1) and foot ulceration 1.7 (1.2, 2.4).

CONCLUSIONS

The prevalence of Type 2 diabetes is not high in community-dwelling older people, but diabetes was a contributory factor to a number of health problems.

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

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

Association between quality of primary care and hospitalization for coronary heart disease in England: national cross-sectional study

BACKGROUND

A new pay-for-performance scheme for primary care physicians was introduced in England in 2004 as part of an initiative to link the quality of primary care with physician pay.

OBJECTIVE

To investigate the association between the quality of primary care and rates of hospital admissions for coronary heart disease.

DESIGN

Ecological cross-sectional study using data from the Quality and Outcomes Framework for family practice, hospital admissions, and census data.

PARTICIPANTS

All 303 primary care trusts in England, covering approximately 50 million people.

MEASUREMENTS

Rates of elective and unplanned hospital admissions for coronary heart disease and rates of coronary angioplasty and coronary artery bypass grafting were regressed against quality-of-care measures from the Quality and Outcomes Framework, area socioeconomic scores, and disease prevalence.

RESULTS

Correlations between prevalence, area socioeconomic scores, and admission rates were generally weak. The strongest relations were seen between area socioeconomic scores and elective and unplanned hospital admissions and revascularization procedures among the age group 45-74 years. Among those aged 75 years and over, the only positive association observed was between area socioeconomic scores and unplanned hospital admissions.

CONCLUSIONS

The lack of an association between quality scores and admission rates suggests that improving the quality of primary care may not reduce demands on the hospital sector and that other factors are much better predictors of hospitalization for coronary heart disease.

Hospital admissions by socio-economic status: does the Inverse care law‘ apply to older Australians?

OBJECTIVE

To investigate whether the 'inverse care law' applies to New South Wales (NSW) hospital admissions--especially to older people with high socio-economic status (SES).

DESIGN

Cross-sectional study analysing inequalities in public and private hospital admission rates by SES, defined in terms of age, sex and family income/size at the small geographic area level.

SETTING

Admissions to NSW public and private hospitals in 1999-2000 (1.8 million admissions against a NSW population of 6.4 million).

METHODOLOGY

Inequalities in hospitalisation rates were expressed as rate ratios across the most and least disadvantaged 20% of the NSW population.

RESULTS

Public hospital admission rates for people aged 0-60 years were 24-35% higher for the most disadvantaged 20% of the NSW population than for the least disadvantaged 20%. For 70+ year-olds the direction of this difference was reversed--being 14% lower for the most disadvantaged 20% of the population (5% higher for public patients). For private hospitals this reversal prevailed for all age groups (23-49% lower). For all hospitals it was 16% and 27% lower for 60-69 and 70+ year-olds respectively, with higher admission rates for top SES 60+ year-olds most pronounced for renal dialysis, chemotherapy, colonoscopies and other diagnostic scopes, rehabilitation and follow-up, and cataract operations.

CONCLUSION

While the 'inverse care law' did apply to 60+ year-olds, it did not apply either to younger NSW hospital users or to public patients in public hospitals.

IMPLICATIONS

Awareness of these SES-level differentials should result in greater equality of access to hospital services, especially by older people.

Concurrent tobacco use in a random sample of UK-resident Bangladeshi men

The literature on concurrent tobacco (CCT) use, i.e., regularly using both smoked and chewed tobacco, is sparse.

OBJECTIVES

This study aims to establish the point prevalence of CCT use in a randomly selected sample of UK-resident Bangladeshi males, compare CCT users with other tobacco users (smokers alone and chewers alone), and model the factors for CCT use and chewing tobacco use alone.

METHODS

A cross-sectional bilingual interview survey collecting data on age, marital status, social class, employment status, home ownership and overcrowding, self-assessed health and chronic illness episodes, social capital, nicotine dependence, and oral pain was used. Carbon monoxide readings validated smoked tobacco use. Logistic regressions were used for data analysis.

RESULTS

The initial response rate was 59 percent. Sample mean age was 40.7 years. CCT prevalence was estimated at 22 percent, practiced by older respondents of limited educational status. CCT users more likely had only average or poor self-rated health and more likely reported current oral pain compared with tobacco smokers. A wife chewing tobacco distinguished CCT users, as compared with tobacco smokers alone.

CONCLUSIONS

In this sample of adult Bangladeshi males, CCT use was prevalent. CCT users more likely had a partner who was also a tobacco chewer, as compared with tobacco smokers.

The association between the quality of epilepsy management in primary care, general practice population deprivation status and epilepsy-related emergency hospitalisations

OBJECTIVE

To examine whether there is an association between the quality of epilepsy care, as measured by the Quality and Outcomes Framework of the 2004 General Practitioner contract for England, practice population deprivation status and epilepsy-related emergency hospitalisation.

METHODS

Linear regression analysis was used to examine the association between the proportion of epilepsy-treated seizure-free patients and the proportion of epilepsy-treated patients with at least one epilepsy-related emergency hospitalisation at the individual practice level, adjusting for practice population deprivation status. The analysis was subsequently repeated by using the rate of epilepsy-related hospitalisations among epilepsy-treated patients (as opposed to the number of patients with at least one hospitalisation), during the same study period.

RESULTS

After adjusting for practice population deprivation status, there was a significant inverse association between the proportion of epilepsy-treated seizure-free patients and the proportion of epilepsy-treated patients with at least one epilepsy-related emergency hospitalisation. For every 1% increase in the proportion of seizure-free epilepsy-treated patients there was a 0.43% reduction in the number of patients with at least one epilepsy-related emergency hospitalisation (95% Confidence Interval: -0.09 to -0.78, p: 0.014).

DISCUSSION

The findings indicate a significant and relatively strong relationship between the quality of epilepsy management in primary care (proportion of seizure-free patients) and an important care outcome (epilepsy-related emergency hospitalisation). The findings support the current and future use of Quality Outcomes Framework indicators to measure the quality of epilepsy care.

Hospital admission rates for a racially diverse low-income cohort of patients with diabetes: the Urban Diabetes Study

OBJECTIVE

We sought to determine the frequency and costs of hospitalization and to assess possible racial/ethnic disparities in a large cohort of low-income patients with diabetes who had received primary care at municipal health clinics.

METHODS

Administrative data from Philadelphia Health Care Centers were linked with discharge data from Pennsylvania hospitals for March 1993 through December 2001. We tested differences in hospitalization rates and mean hospital charges by age, gender, and race/ethnicity.

RESULTS

A total of 18,800 patients with diabetes experienced 30,528 hospital admissions, for a hospitalization rate of 0.35 per person-year. Rates rose with age and with the interaction of male gender and age. Rates for non-Hispanic Whites were higher than those for African Americans, whereas those for Hispanics, Asian Americans, and "others" were lower. Patients who were hospitalized at least 5 times made up 10.5% of the study population and accounted for 64% of hospital admissions and hospital charges in this cohort.

CONCLUSIONS

Hospitalization rates for this low-income cohort with access to primary care and pharmacy services were comparable to those of other diabetic patient populations, suggesting that reducing financial barriers to care may have benefited these patients. A subgroup of patients with multiple hospitalizations accounted for the majority of hospital admissions.

Association of population and practice factors with potentially avoidable admission rates for chronic diseases in London: cross sectional analysis

OBJECTIVES

To examine the association between underlying ill health, material deprivation and primary care supply factors and hospital admission rates for potentially avoidable admissions in primary care trusts in London.

DESIGN

Cross sectional analysis at primary care trusts level using routine data from multiple sources.

SETTING

All 31 primary care trusts in London with a total resident population of 7 million patients.

MAIN OUTCOME MEASURES

Age-standardized hospital admission rates for asthma, diabetes, heart failure, hypertension and chronic obstructive pulmonary disease.

RESULTS

Admission rates varied widely for the conditions examined across the 31 primary care trusts. In 2001, age adjusted admission rates for asthma varied from 76 to 189 per 100,000 and for diabetes from 38 to 183 per 100,000. There was a significant association between higher admission rates and measures of underlying ill health and material deprivation but not quantitative measures of primary care service provision. Provision of specialist chronic disease services in primary care for diabetes but not for asthma were significantly associated with reduced admission rates. There was no association of prescribing levels in primary care trusts with admission rates for any of the conditions examined.

CONCLUSIONS

Although hospital admission for some chronic diseases is potentially avoidable and rates of hospital admission for these conditions are possible indicators of the quality of care, they should be interpreted in conjunction with measures of population composition and deprivation. Failure to do this may result in primary care trusts and general practitioners being criticized for aspects of health care utilization that are not under their direct control.

The importance of comorbidity in analysing patient costs in Swedish primary care

Background

The objective was to explore the usefulness of the morbidity risk adjustment system Adjusted Clinical Groups^® (ACG), in comparison with age and gender, in explaining and estimating patient costs on an individual level in Swedish primary health care. Data were retrieved from two primary health care centres in southeastern Sweden.

Methods

A cross-sectional observational study. Data from electronic patient registers from the two centres were retrieved for 2001 and 2002, and patients were grouped into ACGs, expressing the individual combination of diagnoses and thus the comorbidity. Costs per patient were calculated for both years in both centres. Cost data from one centre were used to create ACG weights. These weights were then applied to patients at the other centre. Correlations between individual patient costs, age, gender and ACG weights were studied. Multiple linear regression analyses were performed in order to explain and estimate patient costs.

Results

The variation in individual patient costs was substantial within age groups as well as within ACG weight groups. About 37.7% of the individual patient costs could be explained by ACG weights, and age and gender added about 0.8%. The individual patient costs in 2001 estimated 22.0% of patient costs in 2002, whereas ACG weights estimated 14.3%.

Conclusion

ACGs was an important factor in explaining and estimating individual patient costs in primary health care. Costs were explained to only a minor extent by age and gender. However, the usefulness of the ACG system appears to be sensitive to the accuracy of classification and coding of diagnoses by physicians.

The emergency department as an asthma surveillance tool at the community level: a decline in the burden of pediatric asthma in halifax, Canada

We report pediatric emergency department (PED) asthma visit and inpatient asthma (AS) admission data in our area over a 5-year period. AS visits decreased by 33.9%, AS admissions by 24.6%, both significant compared with the decline in elementary school enrollment. The decrease in asthma visits was due to a decrease in the number of asthmatic patients, not a decline in repeat visits, or use of alternate venues of care. Explanations include a decrease in the burden of disease or an improvement in ambulatory care, but not alternate treatment venues or improvement in acute (PED) care. Readily available, emergency department data are useful in the community surveillance of asthma.

Correlations of siblings' and mothers' utilisation of primary and hospital health care: a record linkage study in Western Australia

A relationship between maternal and child use of general practitioners (GPs) has been shown to exist for some time, however, the reasons for this relationship are not clear and the extent to which this relationship extends to tertiary care is unknown. The aim of this study was to examine the relationships between the utilisation of health care by siblings and mothers over a 14 year period. A retrospective cohort study of 756 mothers and their 1494 children up to age 14 years was conducted in three general practices in Western Australia. Medicare claims and hospital morbidity records for 1984-1997 were linked using deterministic and probabilistic matching. Generalised Estimating Equations and correlations were used to examine the relationships between the utilisation of primary and hospital health care by family members. Significant correlations were found between hospital admissions of all participants and their GP visits, specialist visits, pathology and diagnostic imaging combined and hospital length of stay. There was a strong association between siblings' use of GPs. A child's rate of GP attendance increased with that of its mother. There was a weak but significant relationship between siblings' use of hospitals, and a child's hospital admission rate increased with that of its mother. It is concluded that there is a strong relationship between siblings' use of GPs and a weaker but still significant association between the hospital admissions of siblings. As expected, there were strong associations between mother and child visits to GPs. There was also an association between a mother's use of hospital and that of her children. This finding reduces the plausibility that the relationships found between utilisation of health care by siblings and mothers can be explained entirely by behavioural factors, and suggests the presence of intergenerational correlation of morbidity.