An overview of evaluations of initiatives to reduce emergency admissions. Sarah Purdy December 1st 2014

Transcription

1 An overview of evaluations of initiatives to reduce emergency admissions Sarah Purdy December 1st 2014

2 Which emergency admissions are avoidable? Ambulatory care sensitive conditions (ACSC) are conditions for which hospital admission could be prevented by interventions in primary care 5.2 million admissions a year 1.2 million are avoidable Increasing around 3% a year Urgent and Emergency Care Review 2013 But is quality of care improved or compromised?

3 Urgent and emergency care review

4 Interventions to reduce avoidable admission Primary care Predictive model Practice features Medication review Case management Telemedicine Hospital at home Virtual wards Emergency department Assessment/ observation wards GPs in AE Senior clinician review Hospital Structured discharge Medication review Co-ordination of EOL care Post discharge Transition case management Rehabilitation Selfmanagement & education Specialist clinics

5 Predictive modelling patterns in routine data used to identify high risk people Goodness of fit R Acknowledgement: Nuffield Trust

6 Implementation Risk threshold score Assumed reduction in admissions Cost of the intervention Targeting intervention taking into account cost effectiveness Most current readmission risk prediction models...perform poorly. Kansagara JAMA 2011 Acknowledgement: Nuffield Trust

7 General practice features Impact of overall size of a GP practice is conflicting Proximity to hospital increases admission GP training practice decreases risk of admission 340 million GP consultations per annum Average number consultations rose from 4.1 to to 2008

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9 Better access to GPs reduces admissions Cross sectional studies from the UK suggest evidence of association between poorer perceived access to care and more admissions for long term conditions Huntley BMJ Open 2014, Calderón-Larrañaga Thorax, 2011, Soljak BJGP 2011, Bottle Br J Cancer 2012 Evidence on GP supply is mixed

10 Continuity of care appears to be helpful There is encouraging evidence on continuity of care and admissions. However data suggests the effect may be context and condition-specific The evidence for benefit of QOF measures for specific conditions has been mixed Huntley BMJ Open 2014

11 Percentage differences between trend adjusted emergency admission rates for incentivised ACSCs (ambulatory care sensitive conditions) and non-incentivised ACSCs and non-acscs. Harrison M J et al. BMJ 2014;349:bmj.g by British Medical Journal Publishing Group

12 Medication reviews in the community don t seem to help reduce admissions in older patients Thomas Age and Ageing 2013

13 General practice - Summary of evidence. Generally, better access associated with reduced rates of admissions for long term conditions Being able to see the same health care professional associated with reduced admissions Evidence relating to quality of care limited but suggests QOF incentivised conditions have reduced rates of admission Medication reviews by pharmacists don't seem to help Proximity to health care provision influences patterns of use Huntley BMJ Open 2014

14 Care can be complex and confusing

15 Does case management prevent admissions in older /elderly people? 11/14 studies showed no effect of case management on emergency admissions Huntley Family Practice 2013 Case management initiated in hospital or on discharge versus usual care in the older population: relative rate of readmissions

16 but heart failure patients do benefit from intensive patient focused transition case management on discharge Huntley Family Practice 2013

17 and...intensive case management works in mental health Compared to standard care ICM was shown to reduce hospitalisation and increase retention in care ICM emphasises the importance of small caseload (less than 20) and high intensity input. Dieterich Cochrane 2010

18 Telemedicine expensive?effective Overall evidence is mixed & mainly US May reduce admissions for heart failure, respiratory conditions, diabetes and HT and elderly with LTC (automated vital signs monitoring, telephone follow up by nurses) McLean BMJ 2011 Recent UK evidence Whole System Demonstrator cluster randomised trial showed no difference in emergency admissions when the analysis adjusted for differences in baseline characteristics Steventon BMJ 2012

19 Does intermediate care work? For selected patients, avoiding admission through provision of hospital care at home yielded similar outcomes to inpatient care, at a similar or lower cost Shepperd Cochrane 2009 & 2011 The impact on health service costs of intermediate care s role in...avoiding future hospital admissions, particularly in frail elderly people is not known. Pearson SDO 2013 Evaluation of virtual wards- no evidence of a reduction in emergency hospital admissions Nuffield Trust, 2013

20 Interventions in Emergency Department All types of assessment/observation wards seem to reduce the number of general ward admissions but benefit to patient unclear Cooke Emergency Medicine 2003 GPs in A&E may result in fewer referrals for admission. Cost benefits may exist but the evidence is weak. Primary Care Foundation 2010 Senior clinician review reduced inpatient admissions by 11.9% and specifically reduced admissions to the acute medical assessment unit by 21.2%. White Emergency Medicine Journal 2010 ED attendance increased by 2 million over last decade to 16 million

21 Reducing readmissions general thoughts Possibly only 27% readmissions preventable Van Walraven CMAJ 2011 Primary drivers 30 day readmissions probably patient population and resources in the community Joynt NEJM 2012 Within hospitals global strategies to reduce readmissions seem to be more effective than disease specific ones Dharmarajan BMJ 2013 It is important to focus on the co-morbidities more often the reason for readmission than the primary condition Donze BMJ 2013

22 Structured discharge from hospital prevents readmission Structured discharge planning tailored to the individual patient results in fewer readmissions Shepperd Cochrane 2009

23 Pharmacist reviews in hospital don t reduce readmissions in general older patients Thomas Age and Ageing, 2013 BUT in older people with heart failure pharmacist review with follow up reduces admission RR 0.75 (0.59, 0.95)

24 1 Specialist clinics for heart failure reduce admissions after 12 months Thomas Heart 2013 Study or Subgroup Atienza 2004 Blue 2001 Bruggink 2007 Capomolla 2002 Doughty 2002 Intervention Usual care Risk Ratio Risk Ratio Events Total Events Total Weight 41.7% 14.4% 11.8% 19.3% 12.8% M-H, Fixed, 95% CI 0.52 [0.38, 0.72] 0.45 [0.24, 0.82] 0.52 [0.26, 1.02] 0.26 [0.13, 0.52] 0.88 [0.52, 1.48] M-H, Fixed, 95% CI Total (95% CI) Total events Heterogeneity: Chi² = 7.94, df = 4 (P = 0.09); I² = 50% Test for overall effect: Z = 6.06 (P < ) 100.0% 0.51 [0.41, 0.63] Absolute risk reduction = 16 per 100 people NNT = Favours intervention Favours usual care The most effective specialist clinics for heart failure start off very intensive and then reduce over time BUT no evidence of benefit from specialist clinics in asthma or older/elderly

25 Rehab for COPD works to reduce readmissions Puhan Cochrane 2011

26 Self-management with education works for COPD Effing Cochrane 2009

27 Coordination of EOL care reduces admissions Marie Curie Delivering Choice Programme Users were: 67% less likely to die in hospital 51% less likely to have an emergency hospital admission in last month and 78% less likely in last 7 days 59% less likely to have A&E attendance in last month and 78% less likely in the last week Care coordination centre appeared to be most effective component Purdy BMJ Supportive and Palliative Care 2013

28 Summary of evidenced based interventions that reduce generic admissions Features of primary care Access and continuity of care Quality of care GP training practices The interventions that have evidence supporting them are those that reflect more traditional qualities of care such as patient education, continuity and coordination of care Service interventions Early senior review in A & E Structured discharge from hospital Advanced planning & co-ordination of EOL Intensive case management (mental health)

29 Some good evidence on interventions that reduce respiratory and cardiac admissions Self-management /education in COPD and adults with asthma Pulmonary rehab in COPD Telemonitoring? Specialist clinics for heart failure BUT case management uncertain not all studies are positive Exercise based cardiac rehab in short term

30 Acknowledgements This research is funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR), NIHR Research for Patient Benefit, the Medical Research Council (MRC) and Marie Curie Cancer Care The views expressed are those of the author and not necessarily those of the NHS, the NIHR, the Department of Health, the MRC or Marie Curie Cancer Care More information on presented material at: archreports/