Potentially preventable emergency hospital admissions

Unplanned hospital admissions are both costly and frequently unpleasant experiences for patients. Many hospital admissions related to long-term conditions could be avoided, if timely and effective care is provided to the patient in the community. These conditions are known as ambulatory care-sensitive (ACS) conditions. Here we look at admission for all ACS conditions in England, and three common chronic conditions - chronic obstructive pulmonary disease (COPD), asthma and diabetes - internationally.

Has the number of ACS admissions increased over time?

ACS admission can be defined on the basis of the most important (primary) diagnosis or as one of the many possible secondary diagnoses. Between 2001/02 and 2013/14 the annual number of emergency admissions for ACS conditions increased by 48%, rising from 704,153 to 1,039,242 – an increase of 335,089. Over the same time period emergency admissions for non-ACS conditions increased by only 34%, meaning that the proportion of all emergency admissions that were ACS increased from 18% in 2001/02 to 20% in 2013/14.

Source: 
Health & Social Care Information Centre, Hospital Episode Statistics (Copyright 2013, Re-used with the permission of the Health & Social Care Information Centre. All rights reserved)

Did all types of ACS condition show the same trend over time?

When ACS admissions are categorised as acute, chronic or other and vaccine preventable, it is evident these groups changed at different rates. The rate of emergency admissions for acute ACS conditions increased by 48%, from 486 admissions per 100,000 population in 2001/02 to 718 in 2013/14. The increase in the other and vaccine preventable category of admissions was even greater (142%), but from a much lower base (81 in 2001/02 to 197 in 2013/14). Rates of admission for chronic ACS conditions remained relatively stable over time (710 in 2001/02, 668 in 2013/14, a decrease of 6%). These latter changes are a positive sign of potential improvements in the management of chronic disease.

Source: 
Health & Social Care Information Centre, Hospital Episode Statistics (Copyright 2013, Re-used with the permission of the Health & Social Care Information Centre. All rights reserved)

What was the trend for conditions with the biggest changes over time?

Looking at the individual conditions it seems that rates of emergency admission for angina had nearly halved since 2001/02, and admissions for congestive heart failure were down by one-quarter. However, the net saving of 110 admissions per 100,000 a year was outweighed by the increase in UTI/pyelonephritis alone (an extra 134 annual admissions per 100,000 since 2001/02). While changes in rates of admission for asthma were not statistically significant, the volume of admissions was so large that it was among the three largest decreases in rate.

Source: 
Health & Social Care Information Centre, Hospital Episode Statistics (Copyright 2013, Re-used with the permission of the Health & Social Care Information Centre. All rights reserved)

Did rates of ACS admission show greater increases in more deprived areas?

Admission rates were much higher in the more deprived populations – a pattern that was consistent over time (back to 2001/02). The admission rate in the most deprived twentieth of the population (vigintile) increased from 2,362 admissions per 100,000 to 2,926, while that for the least deprived vigintile increased from 758 to 922. Rates of admission for people living in deprived areas have increased more than those living in less deprived areas (564 extra admissions per 100,000 in the most deprived vigintile, compared with 164 in the least deprived). Yet the percentage increase was similar (22% compared with 24%), and the relative difference between the most and least deprived remained almost constant over the period.

Source: 
Health & Social Care Information Centre, Hospital Episode Statistics (Copyright 2013, Re-used with the permission of the Health & Social Care Information Centre. All rights reserved)

How does the rate of COPD and asthma admissions compare internationally over time?

Overall, COPD-related hospital admissions are more common than asthma- or diabetes-related hospital admissions.

When comparing the UK with other countries, for both COPD and asthma the age-standardised rate per 100,000 population is relatively high; for asthma, the UK is one of the worst performers of all the comparator countries. However, there has been a reduction in the number of hospital admissions for COPD and asthma in the UK in recent years. For COPD, there was a 16% reduction between 2006 and 2013 (from 253.8 admissions per 100,000 population in 2006 to 212.7 admissions per 100,000 population in 2013). For asthma, the rate dropped by 24 per cent between 2006 and 2013 (from 79.5 admissions per 100,000 population to 60.5 admissions per 100,000 population). This decline in the number of hospital admissions may reflect some improvement in the quality of care provided for these conditions.

Trends in the other countries under analysis in this report vary. For example, there has been a continuous sharp decline in Italy in the number of hospital admissions for COPD and in Ireland in the number of hospital admissions for asthma. In the other countries, trends are more stable. Of all the OECD countries, Italy has the lowest admission rate for COPD and Italy has the lowest rate for asthma. Trends in the UK seen in the OECD data reported here are broadly consistent with those reported in earlier work on adult hospital admissions for ambulatory care sensitive conditions in England (Blunt, 2013).

While the focus in this analysis is not on respiratory deaths, it is worth noting that the inquiry by the All Party Parliamentary Group on Respiratory Health (2014) into respiratory deaths concluded that the quality of services and outcomes in the UK compared very poorly with other countries and that urgent action was needed. The inquiry report highlights that awareness in the population as well as among non-specialist professionals, and the effective implementation of numerous, existing, evidence-based clinical guidelines, should be the priority in order to prevent potentially unnecessary admissions and deaths. Other reports have highlighted concern about the quality of care provided to asthma and COPD patients (Department of Health, 2012; Healthcare Quality Improvement Partnership, 2014b).

Updated June 2017.

How does the rate of diabetes admissions compare internationally over time?

Diabetes is a common chronic condition for which inadequate management can lead to a range of short-term (e.g. diabetic coma) and long-term (e.g. cardiovascular disease, retinopathy and kidney disease) complications. The hospital admission rate in the UK for short- and long-term diabetes complications and uncontrolled diabetes without complications was stable between 2011 (66.3 admissions per 100,000) and 2013 (64.3 admissions per 100,000) one of the lowest rates among the comparator countries.

Both Italy and the Spain had lower rates of admission than the UK, with Italy having the lowest in 2013 (43.5 per 100,000). Despite lower hospital admissions, the estimated prevalence of diabetes in 2014 was higher in Spain(6.8%) than in the UK (5.8%) (OECD, Diabetes prevalence 2016). Ideally, we would like to measure hospital admissions within the diabetes population rather than the general population. Whilst hospital admission rates have been stable in the UK, many adults, but especially children, still do not receive the recommended care for diabetes Royal College of Paediatrics and Child Health, 2015) and there are large variations around Europe in the quality of care provided and diabetes outcomes (e.g. HbA1c control) (see SWEET project.

Updated June 2017.

How does the rate of diabetes lower extremity amputations admissions compare internationally over time?

Looking at the more specific indicator of hospital admission rates for diabetes lower extremity amputations, these have also been stable in the UK since 2006 – at an average of three amputations per 100,000 population. In many of the other countries under analysis, the rate has also been stable. The UK’s performance relative to other countries appears good. However, Italy had just 2.7 amputations per 100,000 population in 2013. Evidence from England suggests that many of the amputations could still be prevented with targeted preventative services and fast access to high-quality foot care (Kerr, 2012). Also, multidisciplinary diabetic foot care teams improve outcomes and reduce costs to the NHS (Kerr, 2012).

It is important to be mindful of the differences in coding practices (e.g. major/minor amputations) that are likely to have an impact on the observed differences between countries. OECD and country experts are working on further improving the quality of the diabetes data.

Updated June 2017.

About this data

There are many different definitions of which conditions should be considered as ACS. The definitions used here are listed in the online appendix to our Focus on Preventable admissions report. For a discussion of the various ways of defining an ACS admission, see Purdy and others (2009).

Definitions and comparability for all the indicators discussed in this report are taken directly from the OECD report Health at a Glance 2013: OECD indicators . Detailed information about the definitions and the source and methods for each country can be found here.

The asthma and COPD indicators are defined as the number of hospital discharges of people aged 15 years and over per 100 000 population.

The indicator for diabetes is based on the sum of three indicators: admissions for short-term and long-term complications and for uncontrolled diabetes without complications. Rates were age-sex standardised to the 2010 OECD population aged 15 and over. Differences in coding practices among countries and the definition of an admission may affect the comparability of data. Differences in disease classification systems, for example between ICD-9-CM and ICD-10-AM, may also affect data comparability.

One of the problems with these indicators is that they look at hospital admissions and do not take account of underlying differences in the prevalence of different conditions. For example, with regard to diabetes, it is not always clear whether lower admission rates are due to a lower prevalence of diabetes in the population or better management of people with diabetes. However, there are several ongoing OECD initiatives that focus on coding practices, dataset structure and data specification, with the aim of making the indicators more useful for international comparison.

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