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Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data.

ABSTRACT: BACKGROUND:The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes. OBJECTIVE:To determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department. METHODS:Retrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ?1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics. RESULTS:The analysis included 2?322?112 emergency admissions (81.9% via an A and E department). With a 5?unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ?95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139?673 fewer GP admissions (456?232 vs 316?559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England. CONCLUSIONS:Among hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.

SUBMITTER: Cowling TE

PROVIDER: S-EPMC4893129 | biostudies-literature | 2016 Jun

REPOSITORIES: biostudies-literature

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Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data.

Cowling Thomas E TE Harris Matthew M Watt Hilary H Soljak Michael M Richards Emma E Gunning Elinor E Bottle Alex A Macinko James J Majeed Azeem A

BMJ quality & safety 20150825 6

<h4>Background</h4>The UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.<h4>Objective</h4>To determine wh ...[more]

PMID: 26306608

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Project description:ObjectiveTo develop and externally validate a risk algorithm (QAdmissions) to estimate the risk of emergency hospital admission for patients aged 18-100 years in primary care.DesignProspective open cohort study using routinely collected data from general practice linked to hospital episode data during the 2-year study period 1 January 2010 to 31 December 2011.Setting405 general practices in England contributing to the national QResearch database to develop the algorithm. Two validation cohorts to validate the algorithm (1) 202 different QResearch practices and (2) 343 practices in England contributing to the Clinical Practice Research DataLink (CPRD). All general practices had data linked to hospital episode statistics at the individual patient level.ParticipantsWe studied 2 849 381 patients aged 18-100 years in the derivation cohort with over 4.6 million person-years of follow-up. 265 573 of these patients had one or more emergency admissions during follow-up. For the QResearch validation cohort, we identified 1 340 622 patients aged 18-100 years with over 2.2 million person-years of follow-up. Of these patients, 132 723 had one or more emergency admissions during follow-up. The CPRD cohort included 2 475 360 patients aged 18-100 years with over 3.8 million person-years of follow-up. 234 204 of these patients had one or more emergency admissions during follow-up. We excluded patients without a valid NHS number and a valid Townsend score.EndpointFirst (ie, incident) emergency admission to hospital in the next 2 years as recorded on the linked hospital episodes records.Risk factorsCandidate variables recorded on the general practitioner computer system including (1) demographic variables (age, sex, strategic health authority, Townsend deprivation score, ethnicity); (2) lifestyle variables (smoking, alcohol intake); (3) chronic diseases; (4) prescribed medication; (5) clinical values (body mass index, systolic blood pressure); (6) laboratory test results (haemoglobin, platelets, erythrocyte sedimentation rate, ratio of total serum cholesterol to high density lipoprotein cholesterol concentrations, liver function tests). We also included the number of emergency admissions in the preceding year based on information recorded on the linked hospital episodes records.ResultsThe final QAdmissions algorithm incorporated 30 variables. When applied to the QResearch validation cohort, it explained 41% of the variation in women and 43% of that in men. The D statistic for QAdmissions was 1.7 in women and 1.8 in men. The receiver operating curve statistic was 0.78 for men and 0.77 for women. QAdmissions had good performance on all measures of discrimination and calibration. The positive predictive value for emergency admissions for the top tenth of patients at highest risk was 42% and the sensitivity was 39%. The results for the CPRD validation cohort were similar.ConclusionsThe QAdmissions model provided a valid measure of absolute risk of emergency admission to hospital in the general population as shown by its performance in a separate validation cohort. Further research is needed to evaluate the cost-effectiveness of using these algorithms in primary care.

Project description:BackgroundIt is unclear what effect the pattern of health-care use before admission to hospital with COVID-19 (index admission) has on the long-term outcomes for patients. We sought to describe mortality and emergency readmission to hospital after discharge following the index admission (index discharge), and to assess associations between these outcomes and patterns of health-care use before such admissions.MethodsWe did a national, retrospective, complete cohort study by extracting data from several national databases and linking the databases for all adult patients admitted to hospital in Scotland with COVID-19. We used latent class trajectory modelling to identify distinct clusters of patients on the basis of their emergency admissions to hospital in the 2 years before the index admission. The primary outcomes were mortality and emergency readmission up to 1 year after index admission. We used multivariable regression models to explore associations between these outcomes and patient demographics, vaccination status, level of care received in hospital, and previous emergency hospital use.FindingsBetween March 1, 2020, and Oct 25, 2021, 33 580 patients were admitted to hospital with COVID-19 in Scotland. Overall, the Kaplan-Meier estimate of mortality within 1 year of index admission was 29·6% (95% CI 29·1-30·2). The cumulative incidence of emergency hospital readmission within 30 days of index discharge was 14·4% (95% CI 14·0-14·8), with the number increasing to 35·6% (34·9-36·3) patients at 1 year. Among the 33 580 patients, we identified four distinct patterns of previous emergency hospital use: no admissions (n=18 772 [55·9%]); minimal admissions (n=12 057 [35·9%]); recently high admissions (n=1931 [5·8%]), and persistently high admissions (n=820 [2·4%]). Patients with recently or persistently high admissions were older, more multimorbid, and more likely to have hospital-acquired COVID-19 than patients with no or minimal admissions. People in the minimal, recently high, and persistently high admissions groups had an increased risk of mortality and hospital readmission compared with those in the no admissions group. Compared with the no admissions group, mortality was highest in the recently high admissions group (post-hospital mortality HR 2·70 [95% CI 2·35-2·81]; p<0·0001) and the risk of readmission was highest in the persistently high admissions group (3·23 [2·89-3·61]; p<0·0001).InterpretationLong-term mortality and readmission rates for patients hospitalised with COVID-19 were high; within 1 year, one in three patients had died and a third had been readmitted as an emergency. Patterns of hospital use before index admission were strongly predictive of mortality and readmission risk, independent of age, pre-existing comorbidities, and COVID-19 vaccination status. This increasingly precise identification of individuals at high risk of poor outcomes from COVID-19 will enable targeted support.FundingChief Scientist Office Scotland, UK National Institute for Health Research, and UK Research and Innovation.

Project description:BackgroundIn children, community-acquired pneumonia is a frequent cause of emergency department (ED) presentation and hospital admission. Quality primary care may prevent some of these hospital visits.AimsThe aim of this study was to identify primary care factors associated with ED presentation and hospital admission of preschool-aged children with community-acquired pneumonia.MethodsA case-control study was conducted by enrolling three groups: children presenting to the ED with pneumonia and admitted (n = 326), or discharged home (n = 179), and well-neighbourhood controls (n = 351). Interviews with parents and primary care staff were conducted and health record review was performed. The association of primary care factors with ED presentation and hospital admission, controlling for available confounding factors, was determined using logistic regression.ResultsChildren were more likely to present to the ED with pneumonia if they did not have a usual general practitioner (GP) (odds ratio (OR) = 2.50, 95% confidence interval (CI) = 1.67-3.70), their GP worked ? 20 h/week (OR = 1.86, 95% CI = 1.10-3.13) or their GP practice lacked an immunisation recall system (OR = 5.44, 95% CI = 2.26-13.09). Lower parent ratings for continuity (OR=1.63, 95% CI = 1.01-2.62), communication (OR = 2.01, 95% CI = 1.29-3.14) and overall satisfaction (OR = 2.16, 95% CI = 1.34-3.47) increased the likelihood of ED presentation. Children were more likely to be admitted when antibiotics were prescribed in primary care (OR = 2.50, 95% CI = 1.43-4.55). Hospital admission was less likely if children did not have a usual GP (OR = 0.22, 95% CI = 0.11-0.40) or self-referred to the ED (OR = 0.48, 95% CI = 0.26-0.89).ConclusionsAccessible and continuous primary care is associated with a decreased likelihood of preschool-aged children with pneumonia presenting to the ED and an increased likelihood of hospital admission, implying more appropriate referral. Lower parental satisfaction is associated with an increased likelihood of ED presentation.

Project description:Importance:Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. Objective:To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. Design, Setting, and Participants:A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. Main Outcomes and Measures:The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. Results:Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). Conclusions and Relevance:After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.

Dataset Information

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data.

Publications

Access to primary care and the route of emergency admission to hospital: retrospective analysis of national hospital administrative data.

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