A new study published this week in the British Medical Journal (BMJ) from the Health Research Board (HRB) Centre for Primary Care Research at RCSI (Royal College of Surgeons in Ireland) in collaboration with the University of Cambridge challenges recent UK healthcare policy which aims to reduce emergency hospital admissions and suggests alternative approaches to this problem are needed. Costly emergency admissions continue to rise and are of increasing interest to healthcare policymakers internationally.
Recently introduced changes to GPs pay mean that as part of a ‘Directed Enhanced Service (see details below), they are now incentivised to identify people in their practice thought to be at high-risk of future emergency admission and offer extra support in the form of ‘case-management. However, the researchers show that emergency admission is a difficult outcome to predict reliably. Electronic tools have been developed to identify people at high-risk but these tools will, at best, only identify a minority of people who will actually be admitted to hospital. In addition, they found that there is currently little evidence that implementing case management for people identified as high-risk actually reduces the risk of future emergency admission.
Reviewing the research evidence in this area the authors suggest alternative options that may have more impact on the use of hospital beds for patients following an emergency admission. One is to focus on reducing the length of time that patients are in hospital - though this depends on resources being available in the community to support patients when they are discharged. Second, a significant proportion of all emergency admissions are readmissions to hospital following discharge and research evidence does support interventions to reduce some of these admissions, especially when several members of the healthcare team (e.g. doctor, nurse, social worker, case manager) are involved in helping patients manage the transition from hospital to home. A third option is to focus on certain medical conditions, such as pneumonia, known to cause avoidable emergency admissions and more likely to respond to intervention interventions in primary care. Finally, the authors suggest that policy efforts should be concentrated in more deprived areas where people are more likely to suffer with multiple chronic medical conditions and are more likely to be admitted to hospital.
Commenting on this publication, lead author and HRB Research fellow Dr Emma Wallace said ‘Reducing emergency admissions is a popular target when trying to curtail spiralling healthcare costs. However, only a proportion of all emergency admissions are actually avoidable and its important that policy efforts to reduce emergency admissions are directed where they are most likely to succeed. Our analysis indicates that current UK healthcare policy targeting people identified as high risk in primary care for case management is unlikely to achieve anticipated reductions in emergency admissions and alternative options need to be considered.
Professor Roland said ‘Too often government policy is based on wishful thinking rather than on hard evidence on what is actually likely to work. In addition, new interventions often arent given enough time to bed in to know whether theyre really working.
Commenting on this publication, senior author and Professor of Health Services Research at the University of Cambridge Professor Martin Roland said ‘Reducing the number of people who are readmitted to hospital, and reducing the length of time that people stay in hospital are both likely to have a bigger effect on hospital bed use than trying to predict admission in the population. Both of these need close working between primary and secondary care and between health and social care.
ENDS
Editors Notes
Directed Enhanced Service (DES)
GPs in England get part of their pay for delivering specific services to improve the quality of care. The best known of these is QOF, the Quality and Outcomes Framework. However, there are a number of other payments, called Directed Enhanced Services (DES), which pay GPs for providing specific services. The ‘Avoiding Unplanned Admissions and Proactive Case Management DES requires GPs to:
• Identify vulnerable older people at risk of emergency hospital admission
• Proactively case manage these patients including identifying a named accountable GP and providing a personalised care plan
• Regularly reviewing emergency admissions and A&E attendances from the practices care and nursing home patients
• Reviewing unplanned admissions and readmissions for vulnerable patients
Details of the scheme are at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/299592/DES_Directions_2014.pdf
HRB Centre
for Primary Care Research at RCSI.
The HRB Centre for Primary Care Research (CPCR) was established in 2008
and is funded by the Health Research Board (HRB) in Ireland. The CPCR is a
national centre for research in primary care in Ireland, led by the Royal
College of Surgeons in Ireland, in collaboration with Trinity College Dublin,
Queen’s University Belfast and more recently the National University of
Ireland, Galway. The CPCR aims to establish evidence-based standards
for the quality of clinical care in vulnerable patient groups-older adults,
children, drug users and pregnant women, with a particular emphasis on effective
medicine monitoring. http://www.hrbcentreprimarycare.ie/
Cambridge Centre for Health Services Research at the University of
Cambridge
The
Cambridge Centre for Health Services Research is a collaboration between the
University of Cambridge and the RAND Europe, RAND’s European Office, also based
in Cambridge. Around twenty researchers from a range of disciplines seek
solutions to delivering high quality healthcare, focused mainly on developed
healthcare systems in the UK and Europe. http://www.cchsr.iph.cam.ac.uk/