Validity of a tool designed to assess the preventability of potentially preventable hospitalizations for chronic conditions.

BACKGROUND: Potentially preventable hospitalizations (PPH) are defined as unplanned hospital admissions which could potentially have been prevented with the provision of effective, timely outpatient care. To better understand and ultimately reduce rates of PPH, a means of identifying those which are actually preventable is required. The Preventability Assessment Tool (PAT) was designed for use by hospital clinicians to assess the preventability of unplanned admissions for chronic conditions. OBJECTIVE: The present study examined the ability of the PAT to distinguish between those unplanned admissions which are preventable and those which are not, compared to the assessments of an Expert Panel. METHODS: Data were collected between November 2014 and June 2017 at three hospitals in NSW, Australia. Participants were community-dwelling patients with unplanned hospital admissions for congestive heart failure, chronic obstructive pulmonary disease, diabetes complications or angina pectoris. A nurse and a doctor caring for the patient made assessments of the preventability of the admission using the PAT. Expert Panels made assessments of the preventability of each admission based on a comprehensive case report and consensus process. RESULTS: There was little concordance between the hospital doctors and nurses regarding the preventability of admissions, nor between the assessments of the Expert Panel and the hospital nurse or the Expert Panel and the hospital doctor. CONCLUSIONS: The PAT demonstrated poor concurrent validity and is not a valid tool for assessing the preventability of unplanned hospital admissions. The use of Expert Panels provides a more rigorous approach to assessing the preventability of such admissions.

Admissions for chronic ambulatory care sensitive conditions - a useful measure of potentially preventable admission?

BACKGROUND: Potentially preventable hospital admission (an admission deemed to be potentially preventable given appropriate care in the community-based healthcare setting) has been a topic of international research attention for almost three decades. Recently this has been largely driven by the imperative to reduce ever-increasing unplanned hospital admissions. However, identifying potentially preventable admissions is difficult. As a result, the population level indicator of admissions for ambulatory care sensitive conditions (ACSCs) has been used as a proxy measure for potentially preventable admission. The adoption of this measure has become common, and in Australia, the rate of admissions for chronic ACSCs is now an important component of measuring health system performance and accountability, and is directly linked to funding. Admission for a chronic ACSC is also used to identify individuals for targeting of interventions to reduce preventable admissions. DISCUSSION: Hospital admission for chronic ACSCs is a population measure based on admission diagnoses, it therefore should not be used to identify individual preventable admissions. At present we are unable to determine individual admissions that are deemed to be preventable or, therefore, articulate the factors associated with admissions which are preventable. As we are currently unable to identify individual admissions that are preventable, little is understood about the underlying causes and factors contributing to preventable admissions. A means of assessing preventability of individual admissions is required. Only then can we explore the antecedents, and patient and clinician perspectives on preventable admissions. Until we have a clearer understanding of this, our capacity to inform policy and program development remains compromised.

Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage.

BACKGROUND: The continued increase in hospital admissions is a significant and complex issue facing health services. There is little research exploring patient perspectives or examining individual admissions among patients with frequent admissions for chronic ambulatory care sensitive (ACS) conditions. This paper aims to describe characteristics of older, rural patients frequently admitted with ACS conditions and identify factors associated with their admissions from the patient perspective. METHODS: Patients aged 65+ resident in North Coast NSW with three or more admissions for selected ACS chronic conditions within a 12 month period, were invited to participate in a postal survey and follow up telephone call. Survey and telephone data were linked to admission and health service program data. Descriptive statistics were generated for survey respondents; logistic regression models developed to compare characteristics of patients with 3 or with 4+ admissions; and comparisons made between survey respondents and non-respondents. RESULTS: Survey respondents (n=102) had a mean age of 77.1 years (range 66-95 years), and a mean of 4.1 admissions within 12 months; 49% had at least three chronic conditions; the majority had low socioeconomic status; one in five (22%) reported some difficulty affording their medication; and 35% lived alone. The majority reported psychological distress with 31% having moderate or severe psychological distress. While all had a GP, only 38% reported having a written GP care plan. 22% of those who needed regular help with daily tasks did not have a close friend or relative who regularly cared for them. Factors independently associated with more frequent (n=4+) relative to less frequent (n=3) admissions included having congestive heart failure (p=0.003), higher social isolation scores (p=0.040) and higher Charlson Comorbidity Index scores (p=0.049). Most respondents (61%) felt there was nothing that could have avoided their most recent admission, although some potential avoidability of admission was described around medication and health behaviours. Respondents were younger and less sick than non-respondents. CONCLUSIONS: This study provides a detailed description of older patients with multiple chronic conditions and a history of frequent admission in rural Australia. Our results suggest that programs targeting medication use, health behaviours and social isolation may help reduce multiple hospital admissions for chronic disease.

Community based service providers' perspectives on frequent and/or avoidable admission of older people with chronic disease in rural NSW: a qualitative study.

BACKGROUND: Frequent and potentially avoidable hospital admission amongst older patients with ambulatory care sensitive (ACS) chronic conditions is a major topic for research internationally, driven by the imperative to understand and therefore reduce hospital admissions. Research to date has mostly focused on analysis of routine data using ACS as a proxy for 'potentially avoidable'. There has been less research on the antecedents of frequent and/or avoidable admission from the perspectives of patients or those offering community based care and support for these patients. This study aimed to explore community based service providers' perspectives on the factors contributing to admission among older patients with chronic disease and a history of frequent and potentially avoidable admission. METHODS: 15 semi-structured interviews with community based providers of health care and other services, and an emergency department physician were conducted. Summary documents were produced and thematic analysis undertaken. RESULTS: A range of complex barriers which limit or inhibit access to services were reported. We classified these as external and internal barriers. Important external barriers included: complexity of provision of services, patients' limited awareness of different services and their inexperience in accessing services, patients needing a higher level or longer length of service than they currently have access to, or an actual lack of available services, patient poverty, rurality, and transport. Important internal barriers included: fear (of change for example), a 'stoic' attitude to life, and for some, the difficulty of accepting their changed health status. CONCLUSIONS: The factors underlying frequent and/or potentially avoidable admission are numerous and complex. Identifying strategies to improve services or interventions for this group requires understanding patient, carer and service providers' perspectives. Improving accessibility of services is also complex, and includes consideration of patients' social, emotional and psychological ability and willingness to use services as well as those services being available and easily accessed.

Secondary prevention of osteoporosis post minimal trauma fracture in an Australian regional and rural population.

OBJECTIVE: Minimal trauma fracture (MTF) is an indication of osteoporosis and risk of future fracture. Our objective was to describe osteoporosis risk identification and secondary prevention in a regional and rural population hospitalised for an MTF. DESIGN: A retrospective inpatient file audit and follow-up telephone interview. SETTING: Patients aged 45 years and over admitted for MTF management to two regional hospitals in northern New South Wales between July 2006 and June 2007. MAIN OUTCOME MEASURES: Proportion of patients who received bone mineral densitometry (BMD) assessment and proportion commenced on osteoporosis medication post fracture. RESULTS: There were 459 patients included in our inpatient file audit. During admission only 16% had osteoporosis risk documented, uptake of vitamin D assay or BMD were minimal and only 22% were discharged on preventive medication. Of 219 patients contacted post discharge, 36% reported discussing osteoporosis risk with their GPs, 22% reported post-discharge BMD and 32% were taking a bisphosphonate. Men were less likely to have commenced preventive medication (OR 0.42, CI, 0.19-0.91) and patients informed of their osteoporosis risk during hospitalisation were more likely to have had BMD (OR 1.93, CI, 1.03-3.61). Neither age nor history of previous MTF was predictive of preventive treatment post discharge. CONCLUSION: Overall, fracture risk identification and initiation of secondary prevention in this regional and rural population was low and this is consistent with findings in recent metropolitan studies. Effective regional and rural strategies are required that ensure identification and effective communication of risk to patients and their GPs.

Population rates of bone densitometry use in Australia, 2001-2005, by sex and rural versus urban location.

OBJECTIVE: To explore use of bone densitometry in Australia and to identify any sex and geographic differences, as a marker of osteoporosis diagnosis and care. DESIGN AND SETTING: Analysis of claims data from Medicare Australia in patients aged over 45 years during the period 2001-2005. MAIN OUTCOME MEASURES: Age-standardised rates of bone densitometry use, by sex and by metropolitan, rural or remote classification. RESULTS: Bone densitometry use increased by 26% over the 5 years. Rates were lower for rural and remote populations, with people in capital cities about three times as likely to undergo the investigation as those in remote areas. The sex ratio for the rate of bone densitometry use (women to men) decreased from more than 6 : 1 in 2001 to 4 : 1 in 2005. CONCLUSION: Although the sex ratio for osteoporotic fracture is close to 2 : 1 (women to men), the sex ratio for testing is much higher, suggesting underuse of bone densitometry in men. Sex and rural inequities in use of the investigation need to be addressed as part of a national approach to reducing minimal trauma fracture.

An evaluation of a SAFE-style trachoma control program in Central Australia.

OBJECTIVES: To evaluate the effectiveness of a trachoma control program in a remote community before and after major environmental health improvements. DESIGN: Before-and-after cross-sectional design. The control program was in three rounds - each consisting of community census, screening of children < 13 years, health promotion activities and antibiotic treatment. There were two housing and infrastructure surveys. INTERVENTIONS: Treatment of affected children and their households with azithromycin at baseline, 7 and 21 months, and health promotions. Housing and sewerage infrastructure improvements were completed at 12 months. SETTING: Large, remote Central Australian Aboriginal community, 1998-2000. PARTICIPANTS: All community residents. MAIN OUTCOME MEASURES: Prevalence of active trachoma among children under 13 years; community population changes; and adequacy of housing facilities for healthy living practices. RESULTS: The prevalence of trachoma among children was 40% (95% CI, 32%-46%) at baseline, 33% (95% CI, 26%-40%) at 7 months' follow-up and 37% (95% CI, 29%-46%) at 21 months. These proportions were neither clinically nor statistically significantly different. There was a high degree of population mobility over the study period, with only 32% of residents appearing in all three censuses. The proportion of houses with completely adequate facilities increased from 0 to 16%. CONCLUSIONS: Population mobility (both within and between communities), inadequate housing and continued crowding (despite improvements), as well as uncertainty about compliance with antibiotic treatment, are the likely factors contributing to the lack of effect of this trachoma control program. Because of high population mobility, a region-wide approach is needed for effective trachoma control.