Redefining avoidable and inappropriate admissions.

OBJECTIVES: Focusing on policy discourse in the United Kingdom, we examine the chain of causation that is characteristic of the ways in which the concepts of avoidability and inappropriateness are defined and used in these contexts. With a particular focus on diabetes complications, we aim to elucidate the way in which avoidable admission to hospital is conceptualised, measured, and applied to policy development and implementation and build a more inclusive model of identification as a basis for further research in this area. STUDY DESIGN: Discourse analysis was used in combination with a scoping review. METHODS: We searched the online databases of the UK Houses of Parliament Hansard, Official reports of the Northern Ireland Assembly and transcripts of the Scottish Parliament in October 2021. We also conducted an electronic search in October 2021 on MEDLINE, PubMed, Google Scholar, EMBASE, CINAHL and The Cochrane Library to review the available literature. In addition, an analysis of policies in place in Scotland, England and Northern Ireland relating to urgent diabetes care was conducted. RESULTS: 'Avoidable' and 'inappropriate' hospital admissions are categories used in health policy and practice internationally as ways of identifying targets for interventions intending to reduce the burden of care. Diabetes mellitus is a chronic condition that is often seen as a costly and avoidable use of health care services and so is a frequent target of such policies. Avoidable admission is interpreted as having a very long chain of causation. The assumption is that people requiring unscheduled hospital admission could have taken steps to prevent the onset of diabetes, or associated complications, arising in the first place. Definitions focus on primary and secondary prevention and largely place responsibility on the individual and their behaviour rather than on structural or social factors. Inadequate or inappropriate care prehospital or in the emergency department is seldom considered as a potential cause of avoidable admissions. Procedural definitions of avoidable admission are proposed whereby health care professionals and people living with diabetes collaborate to identify avoidable admissions in clinical audit rather than using statistical rates of avoidable admission within isolation in policy development and implementation. CONCLUSIONS: Avoidability and inappropriateness are characteristics of cases in which conduct of the individual or attendant health care professionals was a proximate cause of hospital admission, and but for such conduct, admission could have been avoided. This process of definition seeks to provide a basis for contextualised and considered evaluation of where there are problems in care and where there are reasonable opportunities for prevention.

Factors influencing hospital conveyance following ambulance attendance for people with diabetes: A retrospective observational study.

AIM: To assess variables contributing to hospital conveyance for people with diabetes and the interactions between them. A secondary aim was to generate hypotheses for further research into interventions that might reduce avoidable hospital admissions. METHODS: A national retrospective data set including 30 999 diabetes-related callouts from the Scottish Ambulance Service was utilized covering a 5-year period between 2013 and 2017. The relationship between diabetes-related hospital conveyance and seven potential risk factors was analysed. Independent variables included: age, gender, deprivation, paramedic attendance, treatment at the scene, first blood glucose measurement and day of the week. RESULTS: In Scotland, hyperglycaemia was associated with a higher number of people being conveyed to hospital than hypoglycaemia (49.8% with high blood glucose vs. 39.3% with low glucose, P ≤ 0.0001). Treatment provided in pre-hospital care was associated with reduced conveyance rates (47.3% vs. 58.2% where treatment was not administered, P ≤ 0.0001). Paramedic attendance was also associated with reduced conveyance to hospital (51.4% vs. 59.5% where paramedic was not present, P ≤ 0.0001). Paramedic attendance in hyperglycaemic cases was associated with significantly reduced odds of conveyance (odds ratio 0.52, P ≤ 0.001). CONCLUSIONS: A higher rate of conveyance associated with hyperglycaemic cases indicates a need for more resources, education and training in this area. Higher conveyance rates were also associated with no paramedic being present and no treatment being administered. This suggests that paramedic attendance may be crucial in reducing avoidable admissions. Developing and validating protocols for pre-hospital services and treatment may help to reduce hospital conveyance rates.