Exploration of understanding of impactibility analysis and application through workshops to inform model design for population health management policy: a qualitative assessment.

OBJECTIVES: Assess understanding of impactibility modelling definitions, benefits, challenges and approaches. DESIGN: Qualitative assessment. SETTING: Two workshops were developed. Workshop 1 was to consider impactibility definitions and terminology through moderated open discussion, what the potential pros and cons might be, and what factors would be best to assess. In workshop 2, participants appraised five approaches to impactibility modelling identified in the literature. PARTICIPANTS: National Health Service (NHS) analysts, policy-makers, academics and members of non-governmental think tank organisations identified through existing networks and via a general announcement on social media. Interested participants could enrol after signing informed consent. OUTCOME MEASURES: Descriptive assessment of responses to gain understanding of the concept of impactibility (defining impactibility analysis), the benefits and challenges of using this type of modelling and most relevant approach to building an impactibility model for the NHS. RESULTS: 37 people attended 1 or 2 workshops in small groups (maximum 10 participants): 21 attended both workshops, 6 only workshop 1 and 10 only workshop 2. Discussions in workshop 1 illustrated that impactibility modelling is not clearly understood, with it generally being viewed as a cross-sectional way to identify patients rather than considering patients by iterative follow-up. Recurrent factors arising from workshop 2 were the shortage of benchmarks; incomplete access to/recording of primary care data and social factors (which were seen as important to understanding amenability to treatment); the need for outcome/action suggestions as well as providing the data and the risk of increasing healthcare inequality. CONCLUSIONS: Understanding of impactibility modelling was poor among our workshop attendees, but it is an emerging concept for which few studies have been published. Implementation would require formal planning and training and should be performed by groups with expertise in the procurement and handling of the most relevant health-related real-world data.

Social and ethnic group differences in healthcare use by children aged 0-14 years: a population-based cohort study in England from 2007 to 2017.

OBJECTIVE: To describe social and ethnic group differences in children's use of healthcare services in England, from 2007 to 2017. DESIGN: Population-based retrospective cohort study. SETTING/PATIENTS: We performed individual-level linkage of electronic health records from general practices and hospitals in England by creating an open cohort linking data from the Clinical Practice Research Datalink and Hospital Episode Statistics. 1 484 455 children aged 0-14 years were assigned to five composite ethnic groups and five ordered groups based on postcode mapped to index of multiple deprivation. MAIN OUTCOME MEASURES: Age-standardised annual general practitioner (GP) consultation, outpatient attendance, emergency department (ED) visit and emergency and elective hospital admission rates per 1000 child-years. RESULTS: In 2016/2017, children from the most deprived group had fewer GP consultations (1765 vs 1854 per 1000 child-years) and outpatient attendances than children in the least deprived group (705 vs 741 per 1000 child-years). At the end of the study period, children from the most deprived group had more ED visits (447 vs 314 per 1000 child-years) and emergency admissions (100 vs 76 per 1000 child-years) than children from the least deprived group.In 2016/2017, children from black and Asian ethnic groups had more GP consultations than children from white ethnic groups (1961 and 2397 vs 1824 per 1000 child-years, respectively). However, outpatient attendances were lower in children from black ethnic groups than in children from white ethnic groups (732 vs 809 per 1000 child-years). By 2016/2017, there were no differences in outpatient, ED and in-patient activity between children from white and Asian ethnic groups. CONCLUSIONS: Between 2007 and 2017, children living in more deprived areas of England made greater use of emergency services and received less scheduled care than children from affluent neighbourhoods. Children from Asian and black ethnic groups continued to consult GPs more frequently than children from white ethnic groups, though black children had significantly lower outpatient attendance rates than white children across the study period. Our findings suggest substantial levels of unmet need among children living in socioeconomically disadvantaged areas. Further work is needed to determine if healthcare utilisation among children from Asian and black ethnic groups is proportionate to need.

Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: a national observational study.

INTRODUCTION: Hospital admissions in many countries fell dramatically at the onset of the COVID-19 pandemic. Less is known about how care patterns differed by patient groups. We sought to determine whether areas with higher levels of socioeconomic deprivation or larger ethnic minority populations saw larger falls in emergency and planned admissions in England. METHODS: We conducted a national observational study of hospital care in the English National Health Service (NHS) in 2019-2020. Weekly volumes of elective (planned) and emergency admissions in 2020 compared with 2019 were calculated for each census area. Multiple linear regression analysis was used to estimate the reductions in volumes for areas in different quintiles of socioeconomic deprivation and ethnic minority populations after controlling for national time trends and local area composition. RESULTS: Between March and December 2020, there were 35.5% (3.0 million) fewer elective admissions and 22.0% (1.2 million) fewer emergency admissions with a non-COVID-19 primary diagnosis than in 2019. Areas with the largest share of ethnic minority populations experienced a 36.7% (95% CI 24.1% to 49.3%) larger reduction in non-primary COVID-19 emergency admissions compared with those with the smallest. The most deprived areas experienced a 10.1% (95% CI 2.6% to 17.7%) smaller reduction in non-COVID-19 emergency admissions compared with the least deprived. These patterns are not explained by differential prevalence of COVID-19 cases by area. CONCLUSIONS: Even in a healthcare system founded on the principle of equal access for equal need, the impact of COVID-19 on NHS hospital care for non-COVID patients has not been spread evenly by ethnicity and deprivation in England. While we cannot conclusively determine the mechanisms behind these differences, they risk exacerbating prepandemic health inequalities.

Bridging the impactibility gap in population health management: a systematic review.

OBJECTIVES: Assess whether impactibility modelling is being used to refine risk stratification for preventive health interventions. DESIGN: Systematic review. SETTING: Primary and secondary healthcare populations. PAPERS: Articles published from 2010 to 2020 on the use or implementation of impactibility modelling in population health management, reported with the terms 'intervenability', 'amenability', and 'propensity to succeed' (PTS) and associated with the themes 'care sensitivity', 'characteristic responders', 'needs gap', 'case finding', 'patient selection' and 'risk stratification'. INTERVENTIONS: Qualitative synthesis to identify themes for approaches to impactibility modelling. RESULTS: Of 1244 records identified, 20 were eligible for inclusion. Identified themes were 'health conditions amenable to care' (n=6), 'PTS modelling' (n=8) and 'comparison or combination with clinical judgement' (n=6). For the theme 'health conditions amenable to care', changes in practice did not reduce admissions, particularly for ambulatory care sensitive conditions, and sometimes increased them, with implementation noted as a possible issue. For 'PTS modelling', high costs and needs did not necessarily equate to high impactibility and targeting a larger number of individuals with disorders associated with lower costs had more potential. PTS modelling seemed to improve accuracy in care planning, estimation of cost savings, engagement and/or care quality. The 'comparison or combination with clinical judgement' theme suggested that models can reach reasonable to good discriminatory power to detect impactable patients. For instance, a model used to identify patients appropriate for proactive multimorbid care management showed good concordance with physicians (c-statistic 0.75). Another model employing electronic health record scores reached 65% concordance with nurse and physician decisions when referring elderly hospitalised patients to a readmission prevention programme. However, healthcare professionals consider much wider information that might improve or impede the likelihood of treatment impact, suggesting that complementary use of models might be optimum. CONCLUSIONS: The efficiency and equity of targeted preventive care guided by risk stratification could be augmented and personalised by impactibility modelling.

Competing risks in quality and safety research: a framework to guide choice of analysis and improve reporting.

When comparing hospitals on their readmission rates as currently done in the Hospital Readmission and Reduction Program (HRRP) in the USA, should we include the competing risk of mortality after discharge, which precludes the readmission, in the analysis? Not including competing risks in current HRRP metrics was raised recently as a limitation with possible unintended consequences, as financial penalties for higher readmission rates are more severe than for higher mortality rates. Incorrectly including or ignoring competing risks can both induce bias. In this paper, we present a framework to clarify situations when competing risks should be taken into account and when they should not. We argue that the research question and the perspective from which it is asked determine whether the competing risk is also of interest and should be included in the analysis, or if only the event of interest should be considered. This information is often not explicitly reported but is needed to interpret whether the results are valid. Using the examples of readmissions and cancer, we show how different research questions fit different perspectives from which these are asked (patient, system, regulatory/insurance). Slightly changing the research question or perspective may thus change the analysis. Even though some may argue that any introduced bias is likely to be small, in the context of the HRRP, even small changes may mean that a hospital will face (higher) financial penalties. The impact of getting it wrong matters.

Stability over time of the "hospital effect" on 30-day unplanned readmissions: Evidence from administrative data.

Past studies showed that hospital characteristics affect hospital performance in terms of 30-day unplanned readmissions, proving the existence of a "hospital effect". However, the stability over time of this effect has been under-investigated. This study offers new evidence about the stability over time of the hospital effect on 30-day unplanned readmissions. Using 78,907 heart failure (HF) records collected from 116 hospitals in the Lombardy Region (Northern Italy) over three years (2010-2012), this study analysed hospital performance in terms of 30-day unplanned readmissions. Hospitals with unusually high and low readmission rates were identified through multi-level regression that combined both patient and hospital covariates in each year. Our results confirm that although hospital covariates - and the connected managerial choices - affect the 30-day unplanned readmissions of a specific year, their effect is not stable in the short-term (3 years). This has important implications for pay-for-performance schemes and quality improvement initiatives.

The J-IDEA Pandemic Planner: A Framework for Implementing Hospital Provision Interventions During the COVID-19 Pandemic.

BACKGROUND: Planning for extreme surges in demand for hospital care of patients requiring urgent life-saving treatment for coronavirus disease 2019 (COVID-19), while retaining capacity for other emergency conditions, is one of the most challenging tasks faced by health care providers and policymakers during the pandemic. Health systems must be well-prepared to cope with large and sudden changes in demand by implementing interventions to ensure adequate access to care. We developed the first planning tool for the COVID-19 pandemic to account for how hospital provision interventions (such as cancelling elective surgery, setting up field hospitals, or hiring retired staff) will affect the capacity of hospitals to provide life-saving care. METHODS: We conducted a review of interventions implemented or considered in 12 European countries in March to April 2020, an evaluation of their impact on capacity, and a review of key parameters in the care of COVID-19 patients. This information was used to develop a planner capable of estimating the impact of specific interventions on doctors, nurses, beds, and respiratory support equipment. We applied this to a scenario-based case study of 1 intervention, the set-up of field hospitals in England, under varying levels of COVID-19 patients. RESULTS: The Abdul Latif Jameel Institute for Disease and Emergency Analytics pandemic planner is a hospital planning tool that allows hospital administrators, policymakers, and other decision-makers to calculate the amount of capacity in terms of beds, staff, and crucial medical equipment obtained by implementing the interventions. Flexible assumptions on baseline capacity, the number of hospitalizations, staff-to-beds ratios, and staff absences due to COVID-19 make the planner adaptable to multiple settings. The results of the case study show that while field hospitals alleviate the burden on the number of beds available, this intervention is futile unless the deficit of critical care nurses is addressed first. DISCUSSION: The tool supports decision-makers in delivering a fast and effective response to the pandemic. The unique contribution of the planner is that it allows users to compare the impact of interventions that change some or all inputs.

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study.

BACKGROUND: Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions. METHODS AND FINDINGS: We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26-5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34-8.47, p < 0.001) and sustained trend increase (3.14, 3.08-3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of -22.8 (-24.5 to -21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; -15.0, -15.5 to -14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of -2.28 (-2.98 to -1.57, p = 0.002) and sustained decrease in trend of -0.88 (-1.12 to -0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change -5.04, -7.56 to -2.51, p = 0.011), women aged 20 to 24 years (step change -4.52, -7.48 to -1.57, p = 0.030), and women from the most deprived group (step change -4.40, -6.89 to -1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of -5.31 abortions per 1,000 women, or -38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings. CONCLUSIONS: In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20-24 years and those from deprived backgrounds.

Regional variations in trajectories of long-term readmission rates among patients in England with heart failure.

BACKGROUND: We aimed to compare the characteristics and types of heart failure (HF) patients termed "high-impact users", with high long-term readmission rates, in different regions in England. This will allow clinical factors to be identified in areas with potentially poor quality of care. METHODS: Patients with a primary diagnosis of heart failure (HF) in the period 2008-2009 were identified using nationally representative primary care data linked to national hospital data and followed up for 5 years. Group-based trajectory models and sequence analysis were applied to their readmissions. RESULTS: In each of the 8 NHS England regions, multiple discrete groups were identified. All the regions had high-impact users. The group with an initially high readmission rate followed by a rapid decline in the rate ranged from 2.5 to 11.3% across the regions. The group with constantly high readmission rate compared with other groups ranged from 1.9 to 12.1%. Covariates that were commonly found to have an association with high-impact users among most of the regions were chronic respiratory disease, chronic renal disease, stroke, anaemia, mood disorder, and cardiac arrhythmia. Respiratory tract infection, urinary infection, cardiopulmonary signs and symptoms and exacerbation of heart failure were common causes in the sequences of readmissions among high-impact users in all regions. CONCLUSION: There is regional variation in England in readmission and mortality rates and in the proportions of HF patients who are high-impact users.

Digital phenotyping for assessment and prediction of mental health outcomes: a scoping review protocol.

INTRODUCTION: Rapid advancements in technology and the ubiquity of personal mobile digital devices have brought forth innovative methods of acquiring healthcare data. Smartphones can capture vast amounts of data both passively through inbuilt sensors or connected devices and actively via user engagement. This scoping review aims to evaluate evidence to date on the use of passive digital sensing/phenotyping in assessment and prediction of mental health. METHODS AND ANALYSIS: The methodological framework proposed by Arksey and O'Malley will be used to conduct the review following the five-step process. A three-step search strategy will be used: (1) Initial limited search of online databases namely, MEDLINE for literature on digital phenotyping or sensing for key terms; (2) Comprehensive literature search using all identified keywords, across all relevant electronic databases: IEEE Xplore, MEDLINE, the Cochrane Database of Systematic Reviews, PubMed, the ACM Digital Library and Web of Science Core Collection (Science Citation Index Expanded and Social Sciences Citation Index), Scopus and (3) Snowballing approach using the reference and citing lists of all identified key conceptual papers and primary studies. Data will be charted and sorted using a thematic analysis approach. ETHICS AND DISSEMINATION: The findings from this systematic scoping review will be reported at scientific meetings and published in a peer-reviewed journal.

Impact of preventive primary care on children's unplanned hospital admissions: a population-based birth cohort study of UK children 2000-2013.

BACKGROUND: Universal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC. METHODS: We followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not. RESULTS: Overall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1-4 years) and primary school (5-9 years) children, respectively. Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79-2.00) and vaccine-preventable admissions (HR 4.41, 2.59-7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55-4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17-1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77-2.04, HR 11.43, 8.48-15.39, and HR 4.82, 3.93-5.91, respectively). These associations were modified in children who consulted more in primary care. CONCLUSIONS: A high uptake of preventive primary care from birth is associated with fewer unplanned and ACS admissions in children. However, the clustering of poor health, a lack of preventive care uptake, and social deprivation puts some children with comorbid conditions at very high risk of admission. Strengthening immunisation coverage and preventive primary care in countries with poor UHC could potentially significantly reduce the health burden from hospital admission in children.

Sustained Socioeconomic Inequalities in Hospital Admissions for Cardiovascular Events Among People with Diabetes in England.

PURPOSE: This study aimed to determine changes in absolute and relative socioeconomic inequalities in hospital admissions for major cardiovascular causes among patients with diabetes in England. METHODS: We identified all patients with diabetes aged ≥45 years admitted to the hospital in England between 2004-2005 and 2014-2015 for acute myocardial infarction, stroke, percutaneous coronary intervention, or coronary artery bypass graft. We measured socioeconomic status using the Index of Multiple Deprivation. Diabetes-specific admission rates were calculated for each year by deprivation quintile. We assessed temporal changes using negative binomial regression models. RESULTS: Most admissions occurred among patients aged ≥65 years (71%) and men (63.3%). The number of admissions increased steadily from the least quintile to the most deprived quintile. Patients in the most deprived quintile had a 1.94-fold increased risk of acute myocardial infarction (95% confidence interval [CI], 1.79-2.10), 1.92-fold increased risk of stroke (95% CI, 1.78-2.07), 1.66-fold increased risk of coronary artery bypass graft (95% CI, 1.50-1.74), and 1.76-fold increased risk of percutaneous coronary intervention (95% CI, 1.64-1.89) compared with the least deprived group. Absolute differences in rates between the least and most deprived quintiles did not change significantly for acute myocardial infarction (P = .29) and were reduced for stroke, coronary artery bypass graft, and percutaneous coronary intervention (by 17.5, 15, and 11.8 per 100,000 patients with diabetes, respectively, P ≤ .01 for all). CONCLUSIONS: Socioeconomic inequalities persist in diabetes-related hospital admissions for major cardiovascular events in England. Besides improved risk stratification strategies that consider socioeconomically defined needs, wide-reaching population-based policy interventions are required to reduce inequalities in diabetes outcomes.

Who requires emergency surgery for colorectal cancer and can national screening programmes reduce this need?

INTRODUCTION: Patients undergoing emergency colorectal cancer (CRC) surgery are at higher risk of poor outcome than those managed electively. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome in this cohort subsequent morbidity and mortality as well as quantify their long-term survival. The aim of this national study is to identify groups at high risk of undergoing unplanned CRC surgery and assess short and long-term outcome, subsequent morbidity and mortality as well as quantify their long-term survival. METHODS: The Hospital Episode Statistics (HES) database between the years of 1997-2012 was used to identify all patients that had undergone surgery for colorectal cancer. Multivariable logistic regression analysis and cox regression analyses were undertaken to identify patient factors predictive of undergoing emergency and quantify their long-term survival. RESULTS: A total of 286,591 patients underwent resection for CRC between April 1997 and April 2012, of which 24.3% (69,718 patients) were admitted as emergencies and underwent emergency surgery. Independent predictors of undergoing emergency surgery were female gender (OR 1.23, CI: 1.21-1.25, p < 0.001), older age (>79 years old OR 1.55, CI: 1.50-1.60, p < 0.001), social deprivation (most deprived quintile, OR 1.64, CI: 1.50-1.80, p < 0.001) and Black African/Caribbean ethnicity (OR 1.36, CI: 1.21-1.66, p < 0.001). All cause 30- and 90-day mortality within the emergency group was significantly higher than that for the electively managed patients group (13.3% versus compared with 3.4% at 30-days) as was 90-day (20.0% versus compared with 5.8% at 90-days). Amongst patients eligible for bowel screening there was an approximate 40% significant reduction in the proportion of patients requiring emergency surgery before and after its introduction in 2006 (23.4%-14.9%, p < 0.001). This reduction in emergency surgery included both proximal and distal cancer resections. CONCLUSION: Older, socially deprived and ethnic minority patients with colorectal cancer are more likely to present as emergencies requiring CRC surgery. Public health initiatives, such as bowel cancer screening, appear to have concomitantly reduced emergency and increased elective surgical rates within the eligible cohort. This is likely to have a beneficial impact on population survival. Strategies aimed at preventing emergency presentation by identifying patients at specific risk could improve survival outcome for colorectal cancer surgery in England.

Investigating Adverse Event Free Admissions in Medicare Inpatients as a Patient Safety Indicator.

OBJECTIVE: To investigate adverse event free admissions as a potential, patient-centered indicator aligned directly with the goal of patient safety-freedom from harm. BACKGROUND: Preventable adverse event rates in healthcare could be further reduced. These are generally measured separately, one adverse event at a time. However, this does not reveal whether different patients are affected or the same patients are experiencing multiple events. METHODS: We examined Medicare inpatient hospital administrative datasets for 2009 to 2011, processed using standard criteria. Events were (i) death within 30 days, (ii) unplanned readmissions within 30 days, (iii) long length of stay, (iv) healthcare acquired infections, and (v) established patient safety indicators not present on admission. We defined adverse event free admissions as those without record of any of these events. National rates were calculated by diagnosis group. Risk-adjusted hospital-specific rates of adverse event free admissions were calculated using colorectal procedures as an example. RESULTS: There were 23,991,193 admissions after exclusions. Approximately, 64% went through the acute inpatient Medicare system without record of anything untoward. Multiple events were recorded in 22·7% admissions; 15% of these experienced more than 2 adverse events. Risk-adjusted hospital-specific rates of adverse event free admissions for colorectal procedures showed 131 out of 3786 hospitals below the 99·8% lower control limit of the national upper quartile. CONCLUSIONS: Overall, only 60% of admissions were recorded as adverse event free. Multiple adverse events were common. Even if events are under recorded, this measure could provide an easily understandable and useful baseline for clinicians and managers.

Use of hospital services by age and comorbidity after an index heart failure admission in England: an observational study.

OBJECTIVES: To describe hospital inpatient, emergency department (ED) and outpatient department (OPD) activity for patients in the year following their first emergency admission for heart failure (HF). To assess the proportion receiving specialist assessment within 2 weeks of hospital discharge, as now recommended by guidelines. DESIGN: Observational study of national administrative data. SETTING: All acute NHS hospitals in England. PARTICIPANTS: 82 241 patients with an index emergency admission between April 2009 and March 2011 with a primary diagnosis of HF. MAIN OUTCOME MEASURES: Cardiology OPD appointment within 2 weeks and within a year of discharge from the index admission; emergency department (ED) and inpatient use within a year. RESULTS: 15.1% died during the admission. Of the 69 848 survivors, 19.7% were readmitted within 30 days and half within a year, the majority for non-HF diagnoses. 6.7% returned to the ED within a week of discharge, of whom the majority (77.6%) were admitted. The two most common OPD specialties during the year were cardiology (24.7% of the total appointments) and anticoagulant services (12.5%). Although half of all patients had a cardiology appointment within a year, the proportion within the recommended 2 weeks of discharge was just 6.8% overall and varied by age, from 2.4% in those aged 90+ to 19.6% in those aged 18-45 (p<0.0001); appointments in other specialties made up only some of the shortfall. More comorbidity at any age was associated with higher rates of cardiology OPD follow-up. CONCLUSIONS: Patients with HF are high users of hospital services. Postdischarge cardiology OPD follow-up rates fell well below current National Institute for Health and Care Excellence guidelines, particularly for the elderly and those with less comorbidity.

Primary Care Access, Emergency Department Visits, and Unplanned Short Hospitalizations in the UK.

BACKGROUND AND OBJECTIVE: Demand for unplanned hospital services is rising, and children are frequent users, especially where access to primary care is poor. In England, universal health care coverage entitles parents to see a general practitioner (GP) for first-contact care. However, access to GP appointments is variable, and few patients can see their own regular GP out of hours (OOH). The goal of this study explored the association between access to GPs , emergency department (ED) visits and short hospitalizations (<2 days) in children in England. METHODS: ED visit and short hospitalization rates were investigated in 9.5 million children aged <15 years registered with English family practices between April 2011 and March 2012 by using administrative hospital data. Six access categories ranked all practices according to patients' reported ability to schedule GP appointments; from national GP Patient Survey data. GP consulting hours were 8:00 am to 6:30 pm on weekdays. RESULTS: There were 3 074 616 ED visits (56% OOH) and 470 752 short hospitalizations over the 12 months studied. Children registered with practices in the highest access group compared with the lowest were 9% less likely to visit an ED (adjusted rate ratio: 0.91 [95% confidence interval: 0.89-93]), particularly OOH compared with consulting hours (10% vs 7%). Children in the highest access groups were equally likely to be admitted for a short stay. CONCLUSIONS: Increasing GP accessibility might alleviate the burden of ED visits from children, particularly during peak times OOH. Short hospitalizations may be more sensitive to other aspects of health systems.

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

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.

Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions.

PURPOSE: We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions. METHODS: We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions. RESULTS: There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004. CONCLUSIONS: The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.