Use of health services in the last year of life and cause of death in people with intellectual disability: a retrospective matched cohort study

OBJECTIVE

To describe the cause of death together with emergency department presentations and hospital admissions in the last year of life of people with intellectual disability.

METHOD

A retrospective matched cohort study using de-identified linked data of people aged 20 years or over, with and without intellectual disability who died during 2009 to 2013 in Western Australia. Emergency department presentations and hospital admissions in the last year of life of people with intellectual disability are described along with cause of death.

RESULTS

Of the 63 508 deaths in Western Australia from 2009 to 2013, there were 591 (0.93%) decedents with a history of intellectual disability. Decedents with intellectual disability tended to be younger, lived in areas of more social disadvantage, did not have a partner and were Australian born compared with all other decedents. A matched comparison cohort of decedents without intellectual disability (n=29 713) was identified from the general population to improve covariate balance.Decedents with intellectual disability attended emergency departments more frequently than the matched cohort (mean visits 3.2 vs 2.5) and on average were admitted to hospital less frequently (mean admissions 4.1 vs 6.1), but once admitted stayed longer (average length of stay 5.2 days vs 4.3 days). People with intellectual disability had increased odds of presentation, admission or death from conditions that have been defined as ambulatory care sensitive and are potentially preventable. These included vaccine-preventable respiratory disease, asthma, cellulitis and convulsions and epilepsy.

CONCLUSION

People with intellectual disability were more likely to experience potentially preventable conditions at the end of their lives. This indicates a need for further improvements in access, quality and coordination of healthcare to provide optimal health for this group.

Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care

OBJECTIVE

To identify trends in emergency admissions for patients with clinical conditions classed as 'ambulatory care sensitive' (ACS) and assess if reductions might be due to improvements in preventive care.

DESIGN

Observational study of routinely collected hospital admission data from March 2001 to April 2011. Admission rates were calculated at the population level using national population estimates for area of residence.

PARTICIPANTS

All emergency admissions to National Health Service (NHS) hospitals in England from April 2001 to March 2011 for people residents in England.

MAIN OUTCOME MEASURES

Age-standardised emergency admissions rates for each of 27 specific ACS conditions (ICD-10 codes recorded as primary or secondary diagnoses).

RESULTS

Between April 2001 and March 2011 the number of admissions for ACS conditions increased by 40%. When ACS conditions were defined solely on primary diagnosis, the increase was less at 35% and similar to the increase in emergency admissions for non-ACS conditions. Age-standardised rates of emergency admission for ACS conditions had increased by 25%, and there were notable variations by age group and by individual condition. Overall, the greatest increases were for urinary tract infection, pyelonephritis, pneumonia, gastroenteritis and chronic obstructive pulmonary disease. There were significant reductions in emergency admission rates for angina, perforated ulcers and pelvic inflammatory diseases but the scale of these successes was relatively small.

CONCLUSIONS

Increases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ACS conditions overall are to be seen as a positive outcome of for NHS.

Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a canadian setting

OBJECTIVE

To determine whether rates of physician visits for ambulatory care sensitive (ACS) conditions are lower for people of low-socioeconomic status than of high-socioeconomic status in an urban population with universal health care coverage.

DATA SOURCES/STUDY SETTING

Physician claims and hospital discharge abstracts from fiscal years 1998 to 2001 for urban residents of Manitoba, Canada. The 1996 Canadian Census public use database provided neighborhood household income information. The study included all continuously enrolled urban residents in the Manitoba Health Services Insurance Plan.

STUDY DESIGN

Twelve ACS conditions definable using 3-digit ICD-9-CM codes permitted cross-sectional and longitudinal comparison of ambulatory visits and hospitalizations. Neighborhood household income data provided a measure of socioeconomic status.

DATA COLLECTION/EXTRACTION METHODS

Files were extracted from administrative data housed at the Manitoba Centre for Health Policy.

PRINCIPAL FINDINGS

All conditions showed a socioeconomic gradient with residents of the lowest income neighborhoods having both more visits and more hospitalizations than their counterparts in higher income areas. Six of nine conditions with a sufficient N showed individuals living in the lowest income neighborhoods to have significantly more ambulatory visits before hospitalization for an ACS condition than did those in the most affluent neighborhoods. Many conditions showed a gradient in rate of hospitalization even after controlling for the number of ambulatory care visits.

CONCLUSIONS

In the Canadian universal health care plan, the poor have reasonable access to ambulatory care for ACS conditions. Ambulatory care may be more effective in preventing hospitalizations among relatively affluent individuals than among the less well off.