Observational Cost-Effectiveness Analysis Using Routine Data: Admission and Discharge Care Bundles for Patients with Chronic Obstructive Pulmonary Disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a prevalent respiratory disease, and accounts for a substantial proportion of unplanned hospital admissions. Care bundles for COPD are a set of standardised, evidence-based interventions that may improve outcomes in hospitalised COPD patients. We estimated the cost effectiveness of care bundles for acute exacerbations of COPD using routinely collected observational data. METHODS: Data were collected from implementation (n = 7) and comparator (n = 7) acute hospitals located in England and Wales. We conducted a difference-in-difference cost-effectiveness analysis using a secondary care (i.e. hospital) perspective to examine the effect on National Health Service (NHS) costs and 90-day mortality of implementing care bundles compared with usual care for patients admitted to hospital with an acute exacerbation of COPD. Adjusted models included as covariates patient age, sex, deprivation, ethnicity and seasonal effects and mixed effects for site. RESULTS: Outcomes and baseline characteristics of up to 12,532 patients were analysed using both complete case and multiply imputed models. Implementation of bundles varied. COPD care bundles were associated with slightly lower secondary care costs, but there was no evidence that they improved outcomes once adjustments were made for site and baseline covariates. Care bundles were unlikely to be cost effective for the NHS with an estimated net monetary benefit per 90-day death avoided from an adjusted multiply imputed model of -£1231 (95% confidence interval - £2428 to - £35) at a high cost-effectiveness threshold of £50,000 per 90-day death avoided. CONCLUSION AND RECOMMENDATIONS: Care bundles for COPD did not appear to be cost effective, although this finding may have been influenced by unmeasured variations in bundle implementation and other potential confounding factors.

The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012-2016.

OBJECTIVE: To investigate whether the introduction of a named general practitioner (GP, family physician) improved patients' healthcare for patients aged 75 and over in England. SETTING: Random sample of 27 500 patients aged 65 to 84 in 2012 within 139 English practices from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. DESIGN: Prospective cohort approach, measuring patients' GP consultations and emergency hospital admissions 2 years before/after the intervention. Patients were grouped in (i) aged over 74 and (ii) younger than 75 in both periods in order to compare who were or were not subject to the intervention. Adjusted associations between the named GP scheme, continuity of care and emergency hospital admission were examined using multilevel modelling. INTERVENTION: National Health Service policy to introduce a named accountable GP for patients aged over 74 in April 2014. MAIN OUTCOME MEASURES: (A) Continuity of care index-score, (B) risk of emergency hospital admissions, (C) number of emergency hospital admissions. RESULTS: The intervention was associated with a decrease in continuity index-scores of -0.024 (95% CI -0.030 to -0.018, p<0.001); there were no differences in the decrease between the two age groups (-0.005, 95% CI -0.014 to 0.005). In the pre-intervention and post-intervention periods, respectively, 15.4% and 19.4% patients had an emergency admission. The probability of an emergency hospital admission increased after the intervention (OR 1.156, 95% CI 1.064 to 1.257, p=0.001); this increase was bigger for patients over 74 (relative OR 1.191, 95% CI 1.066 to 1.330, p=0.002). The average number of emergency hospital admissions increased after the intervention (rate ratio (RR) 1.178, 95% CI 1.103 to 1.259, p<0.001); this increase was greater for patients over 74 (relative RR 1.143, 95% CI 1.052 to 1.242, p=0.001). CONCLUSION: The introduction of the named GP scheme was not associated with improvements in either continuity of care or rates of unplanned hospitalisation.

Evaluation of 'care bundles' for patients with chronic obstructive pulmonary disease (COPD): a multisite study in the UK.

Background: Chronic obstructive pulmonary disease (COPD) accounts for 10% of emergency hospital admissions in the UK annually. Nearly 33% of patients are readmitted within 28 days of discharge. We evaluated the effectiveness of implementing standardised packages of care called 'care bundles' on COPD readmission, emergency department (ED) attendance, mortality, costs and process of care. Methods: This is a mixed-methods, controlled before-and-after study with nested case studies. 31 acute hospitals in England and Wales which introduced COPD care bundles (implementation sites) or provided usual care (comparator sites) were recruited and provided monthly aggregate data. 14 sites provided additional individual patient data. Participants were adults admitted with an acute exacerbation of COPD. Results: There was no evidence that care bundles reduced 28-day COPD readmission rates: OR=1.02 (95% CI 0.83 to 1.26). However, the rate of ED attendance was reduced in implementation sites over and above that in comparator sites (implementation: IRR=0.63 (95% CI 0.56 to 0.71); comparator: IRR=1.12 (95% CI 1.02 to 1.24); group-time interaction p<0.001). At implementation sites, delivery of all bundle elements was higher but was only achieved in 2.2% (admissions bundle) and 7.6% (discharge bundle) of cases. There was no evidence of cost-effectiveness. Staff viewed bundles positively, believing they help standardise practice and facilitate communication between clinicians. However, they lacked skills in change management, leading to inconsistent implementation. Discussion: COPD care bundles were not effectively implemented in this study. They were associated with a reduced number of subsequent ED attendances, but not with change in readmissions, mortality or reduced costs. This is unsurprising given the low level of bundle uptake in implementation sites, and it remains to be determined if COPD care bundles affect patient care and outcomes when they are effectively implemented. Trial registration number: ISRCTN13022442.

A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission.

BACKGROUND/OBJECTIVES: There are some older patients who are 'at the decision margin' of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear. DESIGN: Systematic review of controlled studies (April 2005-December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed. SETTING: Primary and secondary healthcare interface. PARTICIPANTS: People aged over 65 years at risk of an unplanned admission. INTERVENTIONS: Any community-based intervention offered as an alternative to admission to an acute hospital. PRIMARY AND SECONDARY OUTCOMES MEASURES: Reduction in secondary care use, patient-related outcomes, safety and costs. RESULTS: Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities. CONCLUSIONS: This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.

Can a health forecasting service offer COPD patients a novel way to manage their condition?

OBJECTIVES: The UK Meteorological Office (Met Office) has developed a health forecasting service for chronic obstructive pulmonary disease (COPD) patients, combining a rule-based model predicting risk based on environmental conditions with an anticipatory care intervention providing information on self-management and warnings via an interactive telephone call. Our aim was to explore the acceptability and utility of such a service to patients with COPD and its perceived impact on their behaviour and disease management. METHODS: A cross-sectional questionnaire survey of service users drawn from 189 general practices in England, Scotland and Wales at the end of the winter of 2007/8. RESULTS: Completed questionnaires were received from 3288 COPD patients, representing a response rate of 40%. Eighty-five percent of those returning a questionnaire reported at least one exacerbation during the study period and 8% had been admitted to hospital on one occasion or more. The majority of respondents deemed the information pack (comprising a booklet and thermometers) useful while the automated calls were generally said to be convenient, easy to understand and reassuring. Those less satisfied with the service felt they were already sufficiently aware of the prevailing weather conditions or felt more detailed information was needed. Most benefit was reported by those patients who were willing to be pro-active in the management of their condition, with the service encouraging 36% of respondents to seek a repeat prescription, 28% to re-read their information pack and 12% to consult their GP for worsening of symptoms. CONCLUSIONS: Patients found the automated interactive calling, combined with a health risk forecast, both viable and useful, welcoming the information and tools it offered. In many cases, it added to patients' understanding of their illness and promoted better self-management. Future research should focus on the potential impact of the service in terms of health outcomes and cost-effectiveness.

The impact of co-located NHS walk-in centres on emergency departments.

OBJECTIVES: To determine the impact of establishing walk-in centres alongside emergency departments (EDs) on attendance rates, visit duration, process, costs and outcome of care. METHODS: Eight hospitals with co-located EDs and walk-in centres were compared with eight matched EDs without walk-in centres. Site visits were conducted. Routine data about attendance numbers and use of resources were analysed. A random sample of records of patients attending before and after the opening of walk-in centres was also assessed. Patients who had not been admitted to hospital were sent a postal questionnaire. RESULTS: At most sites, the walk-in centres did not have a distinct identity and there were few differences in the way services were provided compared with control sites. Overall, there was no evidence of an increase in attendance at sites with walk-in centres, but considerable variability across sites was found. The proportion of patients managed within the 4 h National Health Service target improved at sites both with and without walk-in centres. There was no evidence of any difference in reconsultation rates, costs of care or patient outcomes at sites with or without walk-in centres. CONCLUSIONS: Most hospitals in this study implemented the walk-in centre concept to a very limited extent. Consequently, there was no evidence of any effect on attendance rates, process, costs or outcome of care.

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis.

OBJECTIVES: To assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services. DESIGN: Time series analysis in walk-in centre sites with no-treatment control series in matched sites. SETTING: Walk-in centres and matched control towns without walk-in centres in England. PARTICIPANTS: 20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town. MAIN OUTCOME MEASURES: Mean number (accident and emergency departments) or rate (general practices and out of hours services) of consultations per month in the 12 month periods before and after an index date. RESULTS: A reduction in consultations at emergency departments (-175 (95% confidence interval -387 to 36) consultations per department per month) and general practices (-19.8 (-53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services. CONCLUSION: It will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

Questionnaire survey of users of NHS walk-in centres: observational study.

BACKGROUND: NHS walk-in centres have recently been established throughout England to improve access to primary health care. AIM: To determine the characteristics and experiences of people consulting NHS walk-in centres compared with general practice. DESIGN OF STUDY: Observational study using questionnaires. SETTING: Thirty-eight walk-in centres and 34 neighbouring general practices. METHOD: People attending randomly selected survey sessions at walk-in centres or neighbouring general practices on a 'same-day' basis were given a self-administered questionnaire. This collected data about socio-demographic characteristics, reasons for consulting, attitudes to continuity, satisfaction, enablement, referrals, and intentions. RESULTS: Walk-in centre visitors were more likely to be owner-occupiers (55% versus 49%; P<0.001), to have further education (25% versus 19%; P = 0.006), and to be white (88% versus 84%; P< 0.001) than general practice visitors. Main reasons for attending a walk-in centre were speed of access and convenience. Walk-in centre visitors were more likely to attend on the first day of illness (28% versus 10%; P<0.001), less likely to expect a prescription (38% versus 70%, P<0.001), and placed less importance on continuity of care (adjusted odds ratio = 0.58; 95% CI = 0.50 to 0.68) than general practice visitors. People were more satisfied with walk-in centres (adjusted mean difference = 6.6%; 95% CI = 5.0% to 8.2%). Enablement scores were slightly higher in general practice (adjusted mean difference = 0.40; 95 % CI = 0.11 to 0. 6). Following the consultation 13% of walk-in centre visitors were referred to general practice, but 32% intended to make an appointment. CONCLUSION: NHS walk-in centres improve access to care, but not necessarily for those people with greatest health needs. People predominantly attend with problems of recent onset as an alternative to existing health providers, and are very satisfied with the care received. These benefits need to be considered in relation to the cost, and in comparison with other ways of improving access to health care.