Simple approaches to characterising multiple long-term conditions (multimorbidity) and rates of emergency hospital admission: Findings from 495,465 UK Biobank participants

BACKGROUND

Numerous approaches are used to characterise multiple long-term conditions (MLTC), including counts and indices. Few studies have compared approaches within the same dataset. We aimed to characterise MLTC using simple approaches, and compare their prevalence estimates of MLTC and associations with emergency hospital admission in the UK Biobank.

METHODS

We used baseline data from 495,465 participants (age 38-73 years) to characterise MLTC using four approaches: Charlson index (CI), Byles index (BI), count of 43 conditions (CC) and count of body systems affected (BC). We defined MLTC as more than two conditions using CI, BI and CC, and more than two body systems using BC. We categorised scores (incorporating weightings for the indices) from each approach as 0, 1, 2 and 3+. We used linked hospital episode statistics and performed survival analyses to test associations with an endpoint of emergency hospital admission or death over 5 years.

RESULTS

The prevalence of MLTC was 44% (BC), 33% (CC), 6% (BI) and 2% (CI). Higher scores using all approaches were associated with greater outcome rates independent of sex and age group. For example, using CC, compared with score 0, score 2 had 1.95 (95% CI: 1.91, 1.99) and a score of 3+ had 3.12 (95% CI: 3.06, 3.18) times greater outcome rates. The discriminant value of all approaches was modest (C-statistics 0.60-0.63).

CONCLUSIONS

The counts classified a greater proportion as having MLTC than the indices, highlighting that prevalence estimates of MLTC vary depending on the approach. All approaches had strong statistical associations with emergency hospital admission but a modest ability to identify individuals at risk.

A 1-Year Prospective French Nationwide Study of Emergency Hospital Admissions in Children and Adults with Primary Immunodeficiency

PURPOSE

Patients with primary immunodeficiency (PID) are at risk of serious complications. However, data on the incidence and causes of emergency hospital admissions are scarce. The primary objective of the present study was to describe emergency hospital admissions among patients with PID, with a view to identifying "at-risk" patient profiles.

METHODS

We performed a prospective observational 12-month multicenter study in France via the CEREDIH network of regional PID reference centers from November 2010 to October 2011. All patients with PIDs requiring emergency hospital admission were included.

RESULTS

A total of 200 admissions concerned 137 patients (73 adults and 64 children, 53% of whom had antibody deficiencies). Thirty admissions were reported for 16 hematopoietic stem cell transplantation recipients. When considering the 170 admissions of non-transplant patients, 149 (85%) were related to acute infections (respiratory tract infections and gastrointestinal tract infections in 72 (36%) and 34 (17%) of cases, respectively). Seventy-seven percent of the admissions occurred during winter or spring (December to May). The in-hospital mortality rate was 8.8% (12 patients); death was related to a severe infection in 11 cases (8%) and Epstein-Barr virus-induced lymphoma in 1 case. Patients with a central venous catheter (n = 19, 13.9%) were significantly more hospitalized for an infection (94.7%) than for a non-infectious reason (5.3%) (p = 0.04).

CONCLUSION

Our data showed that the annual incidence of emergency hospital admission among patients with PID is 3.4%. The leading cause of emergency hospital admission was an acute infection, and having a central venous catheter was associated with a significantly greater risk of admission for an infectious episode.

Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England

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.

Room for one more? A review of the literature on 'inappropriate' admissions to hospital for older people in the English NHS

This paper reports the findings of a review of the literature on emergency admissions to hospital for older people in the UK, undertaken between May and June 2014 at the Health Services Management Centre, University of Birmingham. This review sought to explore: the rate of in/appropriate emergency admissions of older people in the UK; the way this is defined in the literature; solutions proposed to reduce the rate of inappropriate admissions; and the methodological issues which particular definitions of 'inappropriateness' raise. The extent to which a patient perspective is included in these definitions of inappropriateness was also noted, given patient involvement is such a key policy priority in other areas of health policy. Despite long-standing policy debates, relatively little research has been published on formal rates of 'inappropriate' emergency hospital admissions for older people in the UK NHS in recent years. What has been produced indicates varying rates of in/appropriateness, inconsistent ways of defining appropriateness and a lack of focus on the possible solutions to address the problem. Significantly, patient perspectives are lacking, and we would suggest that this is a key factor in fully understanding how to prevent avoidable admissions. With an ageing population, significant financial challenges and a potentially fragmented health and social care system, the issue of the appropriateness of emergency admission is a pressing one which requires further research, greater focus on the experiences of older people and their families, and more nuanced contextual and evidence-based responses.

Pneumonia Hospitalization Risk in the Elderly Attributable to Cold and Hot Temperatures in Hong Kong, China

The growth of pathogens potentially relevant to respiratory tract infection may be triggered by changes in ambient temperature. Few studies have examined the association between ambient temperature and pneumonia incidence, and no studies have focused on the susceptible elderly population. We aimed to examine the short-term association between ambient temperature and geriatric pneumonia and to assess the disease burden attributable to cold and hot temperatures in Hong Kong, China. Daily time-series data on emergency hospital admissions for geriatric pneumonia, mean temperature, relative humidity, and air pollution concentrations between January 2005 and December 2012 were collected. Distributed-lag nonlinear modeling integrated in quasi-Poisson regression was used to examine the exposure-lag-response relationship between temperature and pneumonia hospitalization. Measures of the risk attributable to nonoptimal temperature were calculated to summarize the disease burden. Subgroup analyses were conducted to examine the sex difference. We observed significant nonlinear and delayed associations of both cold and hot temperatures with pneumonia in the elderly, with cold temperatures having stronger effect estimates. Among the 10.7% of temperature-related pneumonia hospitalizations, 8.7% and 2.0% were attributed to cold and hot temperatures, respectively. Most of the temperature-related burden for pneumonia hospitalizations in Hong Kong was attributable to cold temperatures, and elderly men had greater susceptibility.

Gestational age, birth weight, and risk of respiratory hospital admission in childhood

OBJECTIVE

To investigate the risk of emergency respiratory hospital admission during childhood associated with gestational age at birth and growth restriction in utero.

METHODS

The study included a total population electronic birth cohort with anonymized record-linkage of multiple health and administrative data sets. Participants were 318,613 children born in Wales, United Kingdom, between May 1, 1998, and December 31, 2008. The main outcome measure was emergency respiratory hospital admissions.

RESULTS

The rate of admission in the first year of life ranged from 41.5 per 100 child-years for infants born before 33 weeks' gestation to 9.8 per 100 child-years for infants born at 40 to 42 weeks' gestation. The risk of any emergency respiratory admission up to age 5 years increased as gestational age decreased to <40 weeks. Even at 39 weeks' gestation, there was an increased risk of emergency hospital admissions for respiratory conditions compared with infants born at 40 to 42 weeks (adjusted hazard ratio 1.10; 95% confidence interval 1.08-1.13). Small for gestational age (<10th centile for gestation and gender-specific birth weight) was independently associated with an increased risk of any emergency respiratory admission to hospital (adjusted hazard ratio 1.07; 95% confidence interval 1.04-1.10).

CONCLUSIONS

The risk of emergency respiratory admission up to age 5 years decreased with each successive week in gestation up to 40 to 42 weeks. Although the magnitude of increased risk associated with moderate and late preterm births is small, the number of infants affected is large and therefore presents a significant impact on health care services.

Is greater temperature change within a day associated with increased emergency hospital admissions for heart failure?

BACKGROUND

Although the seasonal variation and the effect of cold temperature on heart failure (HF) morbidity have been well documented, it is unknown whether the temperature variation within a day, that is, diurnal temperature range (DTR), is an independent risk factor for HF. We hypothesized that large DTR might be a source of additional environmental stress and, therefore, a risk factor for HF exacerbation. We aimed to test the association between DTR and HF hospitalization and to examine the effect modifiers, such as age, sex, and season.

METHODS AND RESULTS

We collected daily meteorologic data and emergency HF hospital admissions from 2000 to 2007 in Hong Kong. We used Poisson regression models to fit the relationship between daily DTR and emergency HF hospitalizations, after adjusting for the time trend, seasonality, mean temperature, humidity, and levels of outdoor air pollution. We confirmed the seasonal variation of HF with peak hospital admissions in winter in Hong Kong. The adverse effects of DTR on emergency HF admissions were observed on the current day and lasted for the following several days. Every 1°C increase of DTR at lag0 corresponded to 0.86% (95% confidence interval, 0.31%-1.43%) increment of emergency hospital admissions for HF. DTR exhibited significantly greater effect in the cool season, and on female and elderly patients.

CONCLUSIONS

Greater temperature change within a day was associated with increased emergency hospital admissions for HF. Health policymakers and hospitals may want to take into account the increased demand of specific facilities for susceptive population in winter with greater daily temperature variations.