Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

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Analysis of Trends in Emergency Admissions in E l d 2004 2009 England 20042009 Ian Blunt Ian Blunt Senior Research Analyst www.nuffieldtrust.org.uk

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Transcript of Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Page 1: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Analysis of Trends in Emergency Admissions in E l d 2004 2009England 2004‐2009

Ian BluntIan BluntSenior Research Analyst

www.nuffieldtrust.org.uk

Page 2: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Why emergency admissions?

Emergency hospital admission is:• Undesirable• Undesirable• Expensive• Recorded in routine data• Recorded in routine data

and • Thought to be increasing in numberThought to be increasing in number

Page 3: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Are emergency admissions rising?6000 P ibl

4000

5000

6000

ns (0

00s) Possible reasons

Aging population

3000

4000

admission Public expectations

More treatable illness

1000

2000

mergency  Defensive medicine

Central targets / payment by lt

0

/97

/99

/01

/03

/05

/07

/09

Em results

Changes in other linked services

1996

/

1998

/

2000

/

2002

/

2004

/

2006

/

2008

/ Over reliance on A&E for urgent care

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Is it just emergency admissions?100

All iAll outpatients attendances

Total A&E attendances

10

(millions)

Elective inpatient admissions

1Even

ts 

Emergency admissions

(estimated) Total GP

0.1

5 6 7 8 9 0 1 2 3 4 5 6 7 8 9

(estimated) Total GP consultations

Calls to ambulance services

1994

/95

1995

/96

1996

/97

1997

/98

1998

/99

1999

/00

2000

/01

2001

/02

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

2008

/09 services

England population

Page 5: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Our analysis

The aims of the research were to:• Unpick the rise in admissions• Unpick the rise in admissions• Highlight characteristics of excess admissions• Explore variation at hospital and area level• Explore variation at hospital and area level

This work used the Hospital Episodes StatisticsThis work used the Hospital Episodes Statistics (HES) dataset to examine monthly emergency admissions over a five year period from Apriladmissions over a five year period from April 2004 to March 2009. 

Page 6: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Is the increase due to more readmissions?

Total emergency

Year on year

Increase against

Number of

Increase against

Average admissionsemergency 

admissionsyear 

increaseagainst 2004/05

of individuals

against 2004/05

admissions per person

2004/05 4,441,224 ‐ ‐ 3,229,434 ‐ 1.38/ , , , ,

2005/06 4,666,347 5.1% 5.1% 3,362,317 4.1% 1.39

2006/07 4,707,975 0.9% 6.0% 3,374,751 4.5% 1.40

2007/08 4,771,541 1.4% 7.4% 3,407,204 5.5% 1.40

2008/09 4,964,344 4.0% 11.8% 3,515,537 8.9% 1.41

Page 7: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

Speaking of readmissions...20%6

15%

5

s

10%3

4

gency read

mission

s

ents (m

illions)

5%

1

2 % emerg

Eve

0%0

Number of readmissions Number of discharges to 31/03 %

Data from NCHOD Compendium

Page 8: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

How does the rise consume resources?2 5

2.3

2.4

2.5

ons)

Estimated cost of the rise in emergency admissions is equivalent to at least an dd l ll

2

2.1

2.2

d days (m

illio additional £330 million in 

2008/09 

(compared to 2004/05

1.8

1.9

2

ergency be

d (compared to 2004/05 activity costed at 2008/09 payment levels)

1.5

1.6

1.7Em

Not clipped

Clipped 3 months

However, the actual value is likely to be higher due to inflation in the tariff 1.5

200404

200408

200412

200504

200508

200512

200604

200608

200612

200704

200708

200712

200804

200808

200812 over time and payment 

for non‐tariff work.

Page 9: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

140

Is the pattern of stay length changing?Jan 04: 4‐hour A&E  April 04:Start of our study window

100

120

sion

s in EBD

 

target in forcep y

80

ency adm

iss

gory (0

00s)

EBDs:00

EBDs:01

40

60

er of e

merge

categ EBDs:02

EBDs:03‐05

EDBs:06‐10

EDB 11

0

20

Num

be EDBs:11+

Small scale PbR in foundation trusts

PbR for elective care only

PbR extended to non‐elective care, outpatients and A&E

Apr 2001

Aug

 2001

Dec 2001

Apr 2002

Aug

 2002

Dec 2002

Apr 2003

Aug

 2003

Dec 2003

Apr 2004

Aug

 2004

Dec 2004

Apr 2005

Aug

 2005

Dec 2005

Apr 2006

Aug

 2006

Dec 2006

Apr 2007

Aug

 2007

Dec 2007

Apr 2008

Aug

 2008

Dec 2008

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Is the increase related to age?

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Has the case mix of emergency admission changed?changed?

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Is the increase linked to more A&E visits? 6000

5000

s (000s)

3000

4000

attend

ances

Attendance at major (type 1) A&E

Admission via major 

1000

2000

dmission

s / a

(type 1) A&E

Attendance at all A&E (types 1,2&3)

All d i i i A&E

0

1000Ad All admissions via A&E

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Has the case fatality rate changed?

11%

13%

15%

20000

25000

30000

5%

7%

9%

10000

15000

20000

Deaths

‐1%

1%

3%

0

5000

10000

Observed Expected Percentage of emergency admissions that end with death

Emergency admissions that end in death, showing observed deaths, expected deaths (standardised for age, sex, and HRG at 2004/05 rates) and percentage of total emergency admissions

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Do all trusts exhibit the same pattern?160% 80%

120%

160%

ge

60%

70%

80%

admission

s

40%

80%

n‐year cha

ng

40%

50%

emergency 

‐40%

0%

Year‐on

10%

20%

30%

of sho

rt stay 

‐80%

2005/06 2006/07 2007/08 2008/09

0%

10%

Prop

ortion

 oP

Median, middle 80% range and min/max of 150 stable acute trusts for year‐on‐year change (left) and percentage of short stay emergency admissions (right)

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Is the rise linked to the A&E target?100%600000

95%

400000

500000

e 4 ho

urs

ions

85%

90%

200000

300000

400000

s seen

 inside

chs/Adm

iss

80%100000

200000

% patient

Brea

75%0

Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in England (all A&E types)

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Is the rise linked to the A&E target?

Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in a “normal” trust (all A&E types)

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Is the rise linked to the A&E target?

Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in another trust (all A&E types)

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Do foundation trusts show the same rise? 3.5100%

2.5

3

70%

80%

90%

ns (m

illions)

and total

1.5

2

30%

40%

50%

60%

cy adm

ission

tage of E

ngla

0

0.5

1

0%

10%

20%

30%

Emergenc

Percen

t

00%

2004/05 2005/06 2006/07 2007/08 2008/09

% total emergency admissions recieved by FTs in each year

% total trusts that are FTs in each year

Emergency admissions in trusts achieving FT status by March 2009

Emergency admissions in non‐foundation trust

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Do all PCTs show the same pattern?

Age and sex standardised emergency admission ratio 2004/05 Change in age and sex standardised emergency admission ratio 2004/05 to 2008/09

•Strong correlation with deprivation •No correlation with deprivation or migration•No correlation with baseline SAR

Page 20: Ian Blunt: Analysis of trends in emergency admissions in England 2004-2009

The evidence in summary... Possible reason CommentsAging population Accounts for some of the increase, but not all

Public expectations Increased demand for health servicesPublic expectations Increased demand for health services

More treatable illness No significant change in case mix, although vague symptoms increase disproportionatelyy p p p y

Defensive medicine The increase is due to short stay admissions; but could be many other explanations for these...

Central targets / payment No evidence of 4 hour target driving systematicCentral targets / payment by results

No evidence of 4 hour target driving systematic increase, and slightly pre‐dates PbR

Change in other linked i

Could regional variation in the increase be a symptom f thi ?services of this?

Over reliance on A&E forurgent care

A&E attendance is increasing, as are admissions through A&E

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Efficiency breeds inefficiency paradox?

Reduction in length of stay

More beds available

Provider efficiency System inefficiency

Admission threshold reduced

Less severe cases admitted

Better and more efficient care

Lower acuity cases using costlyefficient care using costly inpatient care

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How might the paradox be addressed?Three main areas that policy makers and commissioners of careThree main areas that policy‐makers and commissioners of care should focus on:

C ti t ti i d f th t f i b i h it l f• Continue to scrutinise and reform the system for reimbursing hospitals for care

• Ensure that shorter stays for admitted patients which free up beds available• Ensure that shorter stays for admitted patients ‐ which free up beds available for care ‐ are translated into reducing the number of hospital beds, rather than lowering the threshold for hospital admission

•Link hospital care more with out‐of‐hospital care providers (primary and community services) and give both incentives to keep people well so that admission is avoided, and disincentives to admit patients to hospital unless absolutely necessary