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, hospital admission rates are higher for COPD than for asthma or diabetes-related conditions. In the UK, the age-sex standardised COPD hospital admission rate is relatively high compared to other OECD countries, and the hospital admission rate for asthma is the highest of all the comparator countries apart from the United States.

However, there has been a slight reduction in hospital admission rates for COPD and asthma in the UK over time. For COPD, there was an 8% reduction from 250.8 admissions per 100,000 population in 2006 to 231.8 admissions per 100,000 population in 2015. For asthma, the rate dropped by 10% from 79.3 admissions per 100,000 population in 2006 to 71 admissions per 100,000 population in 2015. This decrease may reflect some improvement in the quality of care provided for these conditions.

Time trends for the other countries presented here vary considerably. For example, there has been a continuous decrease in hospital admission rates for COPD and asthma in Italy and Finland, but admission rates for these conditions in Germany and the Netherlands have been increasing. Japan has the lowest hospital admission rate for COPD and Italy has the lowest rate for asthma.

While this indicator does not focus 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 was very poor compared to other countries and that urgent action was needed. The inquiry highlighted that awareness in the population as well as among non-specialist professionals, and the effective implementation of existing, evidence-based clinical guidelines, should be prioritised 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 July 2018.

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. Between 2011 and 2015, the hospital admission rate for diabetes in the UK was stable at 72.8 admissions per 100,000 population, which is one of the lowest rates compared to other OECD countries.

Only Portugal, Italy and Spain have lower hospital admission rates for diabetes compared to the UK, with Italy having the lowest rate in 2015 (39.7 admissions per 100,000 population). Despite lower hospital admissions, the estimated prevalence of diabetes in 2015 was higher in Portugal (9.9%), Italy (5.1%) and Spain (7.7%) than in the UK (4.7%) (OECD, Health at a Glance 2017). 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 July 2018.

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

Looking more specifically at hospital admission rates for diabetes lower extremity amputations, these have remained stable over time in the UK, at 2.9 admissions per 100,000 population in 2015. The rate has also been stable in most other OECD countries. The UK has a good level of performance relative to other countries. However, Finland outperformed the UK in 2015 with only 2.8 amputations per 100,000 population. 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 to further improve the quality of the diabetes data.

Updated July 2018.

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 the international indicators are taken directly from the OECD reportHealth at a Glance 2017: 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 admissions with a primary diagnosis of asthma or COPD among people aged 15 years and over per 100,000 population. Rates are age-sex standardised to the 2010 OECD population aged 15 and over. Admissions resulting from a transfer from another hospital and where the patient dies during the admission are excluded from the calculation as these admissions are considered unlikely to be avoidable.

Diabetes avoidable admission is based on the sum of three indicators: admissions for short-term and long-term complications and for uncontrolled diabetes without complications. The indicator is defined as the number of hospital admissions with a primary diagnosis of diabetes among people aged 15 years and over per 100,000 population. Rates were directly age-sex standardised to the 2010 OECD population.

Differences in data definition and coding practices between countries may affect the comparability of data. For example, coding of diabetes as a principal diagnosis versus a secondary diagnosis varies across countries. This is more pronounced for diabetes than other conditions, given that in many cases admission is for the secondary complications of diabetes rather than diabetes itself.

One of the main problems with these indicators is that they look only at hospital admissions and do not take account of differences in disease prevalence. For example, with regard to diabetes, it is not clear whether lower admission rates are due to a lower prevalence of diabetes in the population or better management of people with diabetes.

Comments

Add new comment