Comparative 4-year risk and type of hospital admission among homeless and housed emergency department attendees: longitudinal study of hospital records in England 2013–2018

ObjectivesPeople experiencing homelessness are frequent users of secondary care. Currently, there is no study of potentially preventable admissions for homeless patients in England. We aim to estimate the number of potentially preventable hospital admissions for homeless patients and compare to housed patients with similar characteristics.DesignRetrospective matched cohort study.SettingHospitals in England.Participants16 161 homeless patients and 74 780 housed patients aged 16–75 years who attended an emergency department (ED) in England in 2013/2014, matched on the basis of age, sex, ED attended and primary diagnosis.Primary and secondary outcome measuresAnnual counts of admissions, emergency admissions, ambulatory care-sensitive (ACS) emergency admissions, acute ACS emergency admissions and chronic ACS emergency admissions over the following 4 years (2014/2015–2017/2018). We additionally compare the prevalence of specific ACS conditions for homeless and housed patients.ResultsMean admissions per 1000 patients per year were 470 for homeless patients and 230 for housed patients. Adjusted for confounders, annual admissions were 1.79 times higher (incident rate ratio (IRR)=1.79; 95% CI 1.69 to 1.90), emergency admissions 2.08 times higher (IRR=2.08; 95% CI 1.95 to 2.21) and ACS admissions 1.65 times higher (IRR=1.65; 95% CI 1.51 to 1.80), compared with housed patients. The effect was greater for acute (IRR=1.78; 95% CI 1.64 to 1.93) than chronic (IRR=1.45; 95% CI 1.27 to 1.66) ACS conditions. ACS conditions that were relatively more common for homeless patients were cellulitis, convulsions/epilepsy and chronic angina.ConclusionsHomeless patients use hospital services at higher rates than housed patients, particularly emergency admissions. ACS admissions of homeless patients are higher which suggests some admissions may be potentially preventable with improved access to primary care. However, these admissions comprise a small share of total admissions.

What could prevent chronic condition admissions assessed as preventable in rural and metropolitan contexts? An analysis of clinicians’ perspectives from the DaPPHne study

Introduction Reducing potentially preventable hospitalisations (PPH) is a priority for health services. This paper describes the factors that clinicians perceived contributed to preventable admissions for angina, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), and what they considered might have been done in the three months leading up to an admission to prevent it. Methods The study was conducted in a rural and a metropolitan health district in NSW, Australia. Expert Panels reviewed detailed case reports to assess preventability. For those admissions identified as preventable, comments from clinicians indicating what they perceived could have made a difference and/or been done differently to prevent each of the preventable admissions were analysed qualitatively. Results 148 (46%) of 323 admissions were assessed as preventable. Across the two districts, the most commonly identified groups of contributing factors to preventable admissions were: ‘Systems issues: Community based services missing or inadequate or not referred to’; ‘Patient issues: Problems with adherence/self-management’; and ‘Clinician issues: GP care inadequate’. In some instances, important differences drove these groups of factors. For example, in the rural district ‘Systems issues: Community based services missing or inadequate or not referred to’ was largely driven by social and welfare support services missing/inadequate/not referred to, whereas in the metropolitan district it was largely driven by community nursing, allied health, care coordination or integrated care services missing/inadequate/not referred to. Analyses revealed the complexity of system, clinician and patient factors contributing to each admission. Admissions for COPD (rural) and CHF (metropolitan) admissions showed greatest complexity. Discussion and conclusion These findings suggest preventability of individual admissions is complex and context specific. There is no single, simple solution likely to reduce PPH. Rather, an approach addressing multiple factors is required. This need for comprehensiveness may explain why many programs seeking to reduce PPH have been unsuccessful.

Physical multimorbidity, mental health and unplanned admissions from 2008 to 2018 in Abruzzo region

Background Multimorbidity is defined as the presence of more than one long-term disorder and it is associated with increased use of health services. Socioeconomic deprivation and mental health conditions may lead to undesirable additional unplanned admission to hospital (urgent or emergency admission). This study examines the association among unplanned admission, multimorbidity, mental health and socioeconomic deprivation for both preventable and not preventable hospitalization. Methods We conducted a retrospective analysis of hospital discharge records between 2008 and 2018 in Abruzzo, an Italian region. Multilevel logistic regression models were implemented for both preventable and not preventable unplanned admissions. We set as levels the district of residence and Local Health Authority. As independent variables we used the Italian Deprivation Index of the district of residence to mitigate socioeconomic inequalities, unweighted count of physical health conditions (0, 1, 2, 3, ≥4), the presence of a diagnosis of mental health condition. All the models were also adjusted for age and gender. Results We selected 2,017,720 non preventable admissions, 836,808 (41.45%) of which unplanned, and 152,938 preventable admissions, 107,336 (70.18%) of which unplanned. Both unplanned and potentially unplanned admissions were associated with increasing physical multimorbidity (for ≥4 v. 0 condition, OR 4.85; CI95% 4.26-5.53 for unplanned admission and OR 1.42; CI95% 1.11-1.83 for preventable unplanned admission) and with mental health conditions (OR 1.66; CI95% 1.57-1.75 for unplanned admission and OR 1.18; CI95% 1.00-1.38 for preventable unplanned admission). Conclusions Co-occurrence of physical multimorbidity and mental health condition was associated either with unplanned admission or unplanned preventable admission. Primary care interventions targeting multimorbidity are necessary to reduce the hospital service burden. Key messages Physical multimorbidity substantially affects the use of acute hospital services. Primary care interventions targeting multimorbidity are necessary to reduce the hospital service burden.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice. Objectives To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions. Methods For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA). Results A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights. Limitations The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders. Conclusions Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services. Future work Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions. Funding The National Institute for Health Research Health Services and Delivery Research programme.

GERIATRICS PREVENTABLE ADMISSIONS CARE TEAM (GERIPACT): A HIGH-RISK INTENSIVE AMBULATORY GERIATRICS PROGRAM

The Geriatrics Preventable Admissions Care Team (GERIPACT) is an inter-professional team of 2 clinicians, 1 social worker, and 1 care coordinator, dedicated to offering temporary intensive ambulatory care services to complex older patients at high-risk for incurring expensive health care (ie. frequent emergency room visits or hospitalizations). GERIPACT services include frequent office visits for medical and social work needs, frequent telephone contact, home visits, specialty visit accompaniment, and a 24/7 telephone hotline. Use of this innovative model aims to serve communities lacking in geriatrician and geriatric social work providers, with a main goal of serving the highest risk older population. We reviewed the healthcare utilization of GERIPACT enrollees 6 months prior-to-enrollment and compared with 6 months following graduation from GERIPACT from 2016 to 2018. 78 patients were evaluated, with 49 total ED visits prior to enrollment and 35 post-graduation, saving 14 ED visits for a ratio of 18 saved ED visits per 100 GERIPACT patients. There were 45 hospitalizations prior to enrollment with 29 hospitalizations post-graduation, saving 16 hospitalizations, or 20 hospitalizations per 100 GERIPACT patients. Hospital days were reduced by 237 days post-graduation. An intensive ambulatory program for high risk geriatrics patients may be shown to be an efficient model of care for targeting those older patients who potentially incur greater expenses to the health care system. This focused team may be deployed to primary care communities with complex elderly patients in need of geriatricians and geriatric social workers, and may reduce unnecessary emergency room visits and inpatient stays.

Characteristics of hospitalizations among patients receiving immune checkpoint inhibitors at a community teaching hospital

Purpose As immune checkpoint inhibitors continue to acquire new indications, it is important to understand the impact their use has on patients. This study adds to current literature by presenting an analysis of hospitalizations in this population. The primary objective was to assess the reasons for an emergency department visit or hospital admission in patients who receive immune checkpoint inhibitors. Secondary objectives included identifying the frequency of suspected or confirmed immune related adverse events, types of immune related adverse events, number of preventable admissions, duration of immunotherapy, and length of stay. Methods This study was a retrospective, multi-center, chart review of patients hospitalized after receiving an immune checkpoint inhibitor. The population included patients aged 18 and above who received at least one dose of an immune checkpoint inhibitor at a network facility and had a documented admission within one year following the initiation of immunotherapy. Descriptive statistics were performed along with inferential comparisons and a Poisson regression to determine if the immune checkpoint blocker or cancer type predicted admission or reason for admission. Results The 99 patients who met inclusion criteria had a total of 202 admissions. Of these patients, 56 (56.6%) had multiple admissions within the year following initiation of immunotherapy. The most common diagnoses on initial admissions were shortness of breath, pain, and pneumonia. A total of 104 admissions (51.5%) were considered potentially preventable. Suspected or confirmed immune related adverse events were identified in 15.6% of all admissions. There were no significant predictors of admissions or reason for admission. Conclusion Reasons for admission in the study population were comparable to those identified in the general cancer population, with immune related adverse events being associated with a minority of both total and potentially preventable admissions.

The Transforming Care agenda: admissions and discharges in two English learning disability assessment and treatment units

Purpose The purpose of this paper is to evaluate whether two regional intellectual disability (ID) assessment and treatment (A&T) units in England were meeting the recommended length of stay stipulated by the Learning Disability Professional Senate, in line with the Transforming Care (TC) agenda. A secondary purpose of the study was to evaluate the reasons for admissions and delayed discharges in order to inform how to reduce these. Design/methodology/approach A retrospective evaluation of 85 admissions across two A&T units was conducted over a three-year period (2013–2016) following publication of the TC agenda. Findings There were 85 admissions compared to 71 discharges. Of the 85 admissions, 11 were readmissions. The most common factors thought necessary to prevent admission were early support for care providers or alternative service provision. There were barriers to discharge in over half of admissions; the main reason was a lack of suitable service provision. Practical implications The study suggests that providing specific support or training to care providers could prevent (re)admission and ensure shorter admissions. Further research to establish reasons for the reported lack of suitable providers would be beneficial. Originality/value This study provides current admission and discharge rates for regional A&T units, as recommended by the TC national guidance. It also provides potential reasons underlying preventable admissions and delayed discharges and therefore indicates what might be necessary to prevent admissions and reduce the length of inpatient stays for people with ID and/or autism.