Use of hospital admissions data to quantify the burden of emergency admissions in people with diabetes mellitus.

AIMS: Accurate measurement of emergency diabetes admissions is essential for healthcare delivery and research. This study examines whether current approaches to identifying diabetes-related admissions may underestimate the true burden on hospital care. METHODS: Data spanning the period 1 January 2006 to 31 December 2010 inclusive were extracted from Hospital Episode Statistics data for England. Emergency admissions citing diabetes (E10, E11, E13 or E14) in any diagnosis position in adults (≥ 17 years) were included. E10 and E11 were considered analogous to type 1 and type 2 diabetes mellitus respectively; E13 and E14 were grouped as 'other or unspecified' diabetes mellitus. For admissions citing diabetes multiple times, those with concordant citations were classified as appropriate; discordant citations were assigned to the 'other or unspecified' group. Frequencies of diabetes classifications and complications for each diagnosis position and frequencies of all International Classification of Diseases 10th revision codes for the primary diagnosis field were calculated. RESULTS: In total, 2 443 046 admissions were identified. Diabetes was cited as the primary diagnosis in 6.2% and most commonly cited as the third diagnosis (23.1%). Type 2 diabetes mellitus was the most common (85.0%). The majority of diabetes citations were 'without complication' (2 188 965, 89.6%). The most common primary diagnosis was 'chest pain, unspecified' (R07.4, 99 678, 4.1%). CONCLUSIONS: Reliance on the primary diagnosis field to identify emergency admissions in people with diabetes grossly underestimates the true burden placed on hospital care and leads to underestimates of effect sizes in studies utilizing admission rates as outcome measures. An alternative strategy to identify such admissions is required.

Does higher quality of primary healthcare reduce hospital admissions for diabetes complications? A national observational study.

AIM: To determine if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with primary care diabetes management. METHODS: We performed an observational study in the population in England during the period 2004-2009 (54 741 278 people registered with 8140 general practices). We used multivariable negative binomial regression to model the associations between indirectly standardized hospital admission rates for complications and primary healthcare quality, supply and access indicators, diabetes prevalence and population factors. RESULTS: In multivariate regression models, increasing deprivation (incidence rate ratio: 1.0154; P < 0.001, 95% CI 1.0141-1.0166) and diabetes prevalence (incidence rate ratio: 1.0956; P < 0.001, 95% CI 1.0677-1.1241) were risk factors for admission, while most healthcare covariates, i.e. a larger practice population (incidence rate ratio 0.9999, P = 0.013, 95% CI 0.9999-0.9999), better patient-perceived urgent and non-urgent access to primary care (incidence rate ratio: 0.9989, P = 0.023; 95% CI 0.9979-0.9998 and incidence rate ratio: 0.9988; P = 0.003, 95% CI 0.9980-0.9996, respectively) and better HbA1c target achievement (incidence rate ratio: 0.9971; P < 0.001, 95% CI 0.9958-0.9984), were protective. Diabetes admissions decreased significantly during the period 2004-2009. CONCLUSIONS: After controlling for population factors, better scheduled primary care access and glycaemic control were associated with lower hospital admission rates across most complications. There is little rationale to restrict primary care-sensitive condition definitions to acute complications. They should be revised to improve the usefulness of hospital admission data as an outcome measure, and to facilitate international comparisons. The risk of emergency hospital admission should be monitored routinely.

Association between patient and general practice characteristics and unplanned first-time admissions for cancer: observational study.

BACKGROUND: To identify patient and general practice (GP) characteristics associated with emergency (unplanned) first admissions for cancer in secondary care. METHODS: Patients who had a first-time admission with a primary diagnosis of cancer during 2007/08 to 2009/10 were identified from administrative hospital data. We modelled the associations between the odds of these admissions being unplanned and various patient and GP practice characteristics using national data sets, including the Quality and Outcomes Framework (QOF). RESULTS: There were 639,064 patients with a first-time admission for cancer, with 139,351 unplanned, from 7957 GP practices. The unplanned proportion ranged from 13.9% (patients aged 15-44 years) to 44.9% (patients aged 85 years and older, P<0.0001), with large variation by ethnicity (highest in Asians), deprivation, rurality and cancer type. In unadjusted analyses, all included patient and practice-level variables were statistically significant predictors of the admissions being unplanned. After adjustment, patient area-level deprivation was a key factor (most deprived compared with least deprived quintile OR 1.36, 95% CI 1.32-1.40). Higher total QOF performance protected against unplanned admission (OR 0.94 per 100 points; 95% CI 0.91-0.97); having no GPs with a UK primary medical qualification (OR 1.08, 95% CI 1.04-1.11) and being less able to offer appointments within 48 h were associated with higher odds. CONCLUSION: We have identified some patient and practice characteristics associated with a first-time admission for cancer being unplanned. The former could be used to help identify patients at high risk, while the latter raise questions about the role of practice organisation and staff training.

How many children are fully immunised?

An attempt was made to find the number of confirmed immunisations received by a group of Whangarei four-year-olds. The claims made for the immunisation benefit by each child's general practitioner were compared with questionnaire responses given by the parents of the children. Of 135 parents, 91.1% claimed that their child had received all four early childhood immunisations. Corresponding claims for the immunisation benefit by the child's general practitioner for all four immunisations were found in only 34.9% of cases. There was 79.7% agreement between parental reports and general practitioners' claims for the three-month immunisation. Corresponding figures were 72.3%, 67.2% and 66.4% for the five-, twelve- and eighteen-month immunisations respectively. These findings suggest that many children miss one or two immunisations rather than a few missing most. Present methods of monitoring may therefore tend to over-estimate the level of full immunisation. Computerisation of immunisation data is proposed as an alternative.

Early results from the Northland immunisation register.

A controlled trial to determine the effects of introducing a centralised, computerised immunisation register commenced in Northland in May 1985. All infants born since 1 January 1985 have been registered on the Health Department's mainframe computer and assigned to either control or test groups. This birth information has been used to study two interventions aimed at increasing immunisation levels in the experimental group. The first involves sending to general practitioners lists of infants due for immunisation, and the second sending immunisation reminder cards to parents. Results show significant differences in immunisation levels between test group infants and comparable controls: an 18.2% increase for the six week immunisation, a 16.7% increase for the three month immunisation, and a 4.7% increase for the five month immunisation. A user survey has shown a high degree of acceptance by GPs and practice nurses. The pilot scheme will continue through 1986, and will be used over this period to improve acceptability to users and assist in planning a possible national computerised immunisation information system.

The cardiac waiting game: are patients prioritized on the basis of clinical need?

Waiting lists for coronary artery bypass grafting (CABG) have been a recurring problem for many hospitals, putting pressure on hospitals to manage waiting lists more effectively. In this study, we audited the records of 1594 patients who had coronary artery bypass surgery in 1992 and 1993 in three London hospitals, to assess their waiting time experience. Patients' actual waiting times were compared with an appropriate waiting time defined using an adapted version of a Canadian urgency scoring system. Influence of other factors (sex, age, smoking, hypertension, diabetes and obesity) on actual waiting time was assessed. A comparison of patients' actual waiting times with an appropriate waiting time, defined by the urgency score, showed that only 38% were treated within the appropriate period. Thirty-four per cent were treated earlier than their ischaemic risk indicated, and 28% with high ischaemic risk were delayed. Actual waiting time was associated with a patient's sex and smoking status but not with the other factors studied. The current system of prioritizing patients awaiting CABG is not concordant with a measure of appropriate waiting time. This could have arisen due to a number of factors, including the contracting process, waiting list initiatives, and methods of waiting list administration and patient pressures. The use of a standard method for prioritizing patients would enable a more appropriate use of resources.

Use of time information to maximise theatre utilisation.

This project aimed to investigate how best to define and record theatre use time periods, to determine how much time was lost in theatre, to design reports on theatre time utilisation which were useful and acceptable to surgeons and hospital managers, and to determine whether the use of these reports affected utilisation. Time lost in theatre increased in proportion to the number of cases on the list, from 0% by definition with only one case to 17% with five cases. Over the eight weeks during which utilisation reports were generated and given to surgeons there was a decrease in time lost as a fraction of total time, from 10-11% to 5-6% (not statistically significant, p = 0.06). This was achieved without observable effect on the proportion of allocated time used, which remained fairly stable. The project illustrated the need to alter theatre procedures to minimise time between cases, replace the theatre book with a microcomputer as a precursor to implementation of a computerised theatre information system, and to continue to test utilisation reports as part of a regular utilisation review.

A new syndrome of short stature, joint limitation and muscle hypertrophy.

A further case is presented of a new growth deficiency syndrome first reported by Myre et al. in 1981. The major clinical features are mental retardation, growth deficiency, muscular hypertrophy, joint limitation and abnormal skeletal radiography.

Impact of a promotion program for hepatitis B immunisation.

This study compared levels of hepatitis B immunisation in a group of 524 infants in Northland, New Zealand, with levels in the remainder of the country. The Northland sample had specific encouragement from an immunisation coordinator and had been followed from birth. Levels throughout the rest of the country were estimated from four samples totalling 317 infants whose parents were interviewed when the child was at least two years old. The cross-sectional nationwide sample had fewer children 'fully immunised' by two years of age (minimum estimate 61.8 per cent, maximum estimate 69.7 per cent) than the cohort of children (not lost to follow-up) who were encouraged to have the immunisations in Northland (77.5 per cent) (Z = 4.73, P < 0.001 for comparison with the minimum nationwide estimate; Z = 2.45, P = 0.014 for comparison with the maximum estimate). Of the Northland cohort, 13.5 per cent were lost to follow-up before the scheduled completion of the hepatitis B vaccinations. Assuming that every child lost to follow-up was not fully immunised, the efforts of the immunisation promotion program operated by a nurse coordinator increased the percentage of children fully immunised by between about 7.8 per cent and 15.7 per cent. A promotion program for hepatitis B immunisation, operated by an immunisation coordinator, is an effective tool for increasing immunisation coverage.