Unplanned hospital admissions: defining a set of primary care sensitive admissions and predicting patients at risk.

Lead Research Organisation: University of Bristol
Department Name: Community-Based Medicine

Abstract

Admissions to hospital are an increasing problem for the NHS. Unplanned admissions to hospital are those which are not planned or not from a waiting list. They represent over a third of hospital admissions (4,158,734 emergency admissions in 2003/4). Unplanned admissions are expensive, create uncertainty for those responsible for planning and delivering services and are distressing for patients and their families. This programme includes two linked research studies: The first will tell policy makers and clinicians about the most common reasons for unplanned hospital admission and how costly these admissions are. The research will also explore admissions for conditions that could be treated effectively in primary care and, in consultation with doctors, produce a list of admissions that could be prevented by care outside hospital. This information will help to target future spending and provision of care. The second study will develop and test statistical models, or methods, which will assist primary care clinicians to identify patients at high risk of unplanned admission. This will use primary care medical records and will help both the patient‘s usual GP and nurses, and other colleagues who may not know a patient, to identify people at risk.

Technical Summary

Unplanned hospital admissions: defining a set of primary care sensitive admissions and predicting patients at risk

Admissions to hospital are an increasing source of pressure on NHS resources. Unplanned admissions to hospital are those which are not planned or not from a waiting list. They represent 35.5% of hospital admissions (4,158,734 emergency admissions in 2003/4). Unplanned admissions are expensive in terms of resource use, create uncertainty for those responsible for planning and delivering services and are distressing for patients and their families. There is no evidence on the use of routinely available data from GP records to predict those patients at highest risk from unplanned hospital admission. Recent projects in the UK have used either recent hospital admissions or resource intensive assessment procedures to identify potentially at risk individuals. This programme includes three discrete but linked studies:

Study 1. Describing unplanned hospital admissions and identifying primary care sensitive admissions (PCSA).
A descriptive study of routine data on unplanned admissions at population (PCT) level. Will use HES data to identify rates of unplanned admissions including PCSAs (standardised for age and sex) across PCTs. Costs attributable to admission HRGs will also be obtained. Previously identified associated factors including sociodemographic variables will be included in the analysis. The study will use univariable and multivariable logistic regression to identify a proposed set of PCSAs after modeling to control for predictive variables. Assessment of face and content validity in questionnaire based two stage Delphi process to validate proposed set of PCSAs.
This information will define a set of PCSAs which will assist with the targeting of interventions to prevent admission.

Study 2. Development of a prediction rule for identifying patients at risk of PCSA.
Population based retrospective case-control study of patients admitted to hospital as PCSAs. Cases identified from routine NHS data. Primary care medical record data extracted from GP clinical databases. Univariable and multivariable regression modeling will be used to derive a prediction rule.

Study 3. Validation of a prediction rule for identifying patients at risk of PCSA.
Population based retrospective cohort study of patients. Longitudinal follow up for predictor variables and admission to hospital. Data from GP research database. Testing of predictive models and positive predictive values for risk factors identified in study 2.
The clinical risk tool will assist primary care clinicians to identify patients at high risk of PCSA.

Publications

10 25 50
 
Description Citation in National Outcomes Framework 2010
Geographic Reach UK 
Policy Influence Type Citation in other policy documents
Impact Changed national emeregncy admission indicators to include dementia
 
Description Impact of ACSCs
Geographic Reach UK 
Policy Influence Type Participation in a national consultation
Impact refinement of concept of ACSCs for national primary care policy
 
Description King's Fund Quality indicators project
Geographic Reach UK 
Policy Influence Type Participation in a national consultation
Impact Use of hospital admission data as marker of primary care quality
 
Description SDO call for research funding bids on unplanned admission
Geographic Reach UK 
Policy Influence Type Citation in other policy documents
Impact Research cited as major ongoing work in the field
 
Description Marie Cure Cancer Care research funding
Amount £140,000 (GBP)
Organisation Marie Curie 
Sector Charity/Non Profit
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 02/2011 
End 07/2012
 
Description NHS Research and Development
Amount £60,000 (GBP)
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 01/2008 
End 12/2011
 
Description NIHR National School for Primary Care Research
Amount £200,000 (GBP)
Organisation National Institute for Health Research 
Department School for Primary Care Research
Sector Academic/University
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 01/2012 
End 12/2014
 
Description NIHR Research for Patient Benefit PB-PG-1208-18013 Interventions to reduce unplanned hospital admission: a systematic review
Amount £250,000 (GBP)
Organisation National Institute for Health Research 
Department Research for Patient Benefit
Sector Public
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 06/2010 
End 12/2011
 
Description South West GP Trust
Amount £40,000 (GBP)
Organisation The South West General Practice Trust 
Sector Charity/Non Profit
Country United Kingdom of Great Britain & Northern Ireland (UK)
Start 01/2008 
End 12/2011
 
Description SEAR (Systematic Emergency Admissions Review) Group 
Organisation Cardiff University
Country United Kingdom of Great Britain & Northern Ireland (UK) 
Sector Academic/University 
PI Contribution Leading on series of systematic reviews
Collaborator Contribution Collaboration on a series of systematic reviews
Impact Grants obtained to value of £300,000
Start Year 2007
 
Description Bristol MedChi Conference 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact Presentation of data on unplanned admissions to primary & secondary care professionals and policymakers

Interest from policymakers and clincians
Year(s) Of Engagement Activity 2008,2009
 
Description Evidence on unplanned admissions 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Primary Audience Health professionals
Results and Impact Presnetation to consultant and consultants in training

- invited to present to RCP board by president of RCP
Year(s) Of Engagement Activity 2011
 
Description King's fund 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact Presentation to NHS policy makers and managers on evidence around unplanned hospital admissions

Invited to write policy paper for King's Fund
Year(s) Of Engagement Activity 2010
 
Description North American Primary Care group 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact 300 academics and healthcare professionals, international audience

Approaches from international collaborators
Year(s) Of Engagement Activity 2008,2009
 
Description PCT presentations 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact Presenting to PCT boards on evidence around reducing unplanned admissions

Asked to input to PCT strategy and commissioing decisions
Year(s) Of Engagement Activity 2009,2010
 
Description Society for Academic Primary Care 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Primary Audience Health professionals
Results and Impact What is the impact of practice level variables on emergency hospital admission rates in England? To Society For Academic Primary Care conference, Galway 2008. Awarded NAPCRG/SAPC Prize for best paper.

Invited to NAPCRG to present paper November 2008
Year(s) Of Engagement Activity 2008,2009,2010,2011
 
Description Talks to GP registars 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Primary Audience Health professionals
Results and Impact 30-60 GP registrars per session

Interest from individuals in future academic career
Year(s) Of Engagement Activity 2008,2009,2010