Using data to inform the development of Ireland’s ...Ireland’s Ambulatory Care Framework Eimir Hurley BSc (Pharm) MBiostat, PhD Scholar in Health Services Research ... Cardiology

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Using data to inform the development of Ireland’s Ambulatory Care Framework

Eimir Hurley BSc (Pharm) MBiostat, PhD Scholar in Health Services Research Centre for Health Policy & Management, Trinity College Dublin

Supervisor: Professor Charles Normand, TCD.

Co-supervisor: Dr. Sheena McHugh, UCC; Prof John Browne, UCC; Dr. Louella Vaughan, Nuffield Trust

Presentation at Acute Medicine Conference, September 18, 2018 1

Acknowledgements & Declarations

• PhD funding from the Clinical Strategy & Programme’s Division, HSE

• HIPE-HPO

• NQAIS Clinical

• Individual hospitals – provided consent to use and share their data in the framework

No conflicts of interest in this work, financial or otherwise

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http://www.google.by/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwj9_53c2M7aAhVGUlAKHXCcCKMQjRx6BAgAEAU&url=http://www.sphereprogramme.ie/&psig=AOvVaw2hWeHxSmDA41Uqg_Y059MZ&ust=1524514354520244

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Clarification of limitations of Irish hospital data

• The data presented in this slide deck (and in the associated Ambulatory Care Framework) utilises data from HIPE – Hospital In-Patient Enquiry which captures in-patient and day case activity only.

• Currently, there is no comparable dataset for Emergency presentations or Outpatients activity.

• There is no National data on the clinical conditions seen in Ireland’s Emergency Departments, and the associated conversion rate of these conditions; i.e., we do not know what proportion of episodes with the various clinical conditions presented here are managed in the ED and discharged home fro there without admission to an in-patient bed.

• We do have this data for AMAU activity and can clearly assess the proportion of presentations to the AMAU which are admitted in-house from there, or are discharged home without admission to an in-patient bed, and this is the focus of this body of work.

• In terms of comparing length of stay of patients, it is important to highlight that the length of stay of ‘AMAU episodes’ includes all those episodes which are discharged home from the AMAU without admission to an in-patient bed. Data on comparable episodes in the ED is not available, and the non-AMAU lengths of stay presented here just include those episodes admitted to an in-patient bed. Hence direct comparisons between the two streams cannot be made, but is presented int the report to highlight variation across hospitals.

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Quick overview of Acute Medicine Activity in Irish hospitals

Source: HIPE 2009-2017; NQAIS Clinical 2017

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Acute Medicine Non Acute Medicine

Cardiology Anaesthetics Maxillo-Facial Paediatric E.D. Medicine Psychiatry

Clinical (Medical) Genetics Audiological Medicine Mental Handicap Paediatric Endocrinology Psychogeriatric Medicine

Clinical Immunology Biochemistry Microbiology Paediatric ENT Public Health Medicine

Dermatology Breast Surgery Neonatology Paediatric Gastro-enterology Radiology

Diabetes Mellitus Cardio-Thoracic Surgery Neuro-Ophthalmic Surgery Paediatric Haematology Radiotherapy

Endocrinology Chemical Pathology Neuropathology Paediatric Infectious Diseases Rehabilitation Psychiatry

Gastro-Enterology Child/adolescent Psychiatry Neuroradiology Paediatric Metabolic Medicine Renal Transplantation

General Medicine Clinical Neurophysiology Neurosurgery Paediatric Nephrology Substance Abuse

Genito-Urinary Medicine Clinical Pharmacology Nuclear Medicine Paediatric Neurology Urology

Geriatric Medicine Clinical Physiology Obstetrics Paediatric Neurosurgery Vascular Surgery

Haematology Cytology Obstetrics/Gynaecology Paediatric Oncology Virology

Infectious Diseases Dental Surgery Occupational Medicine Paediatric Orthopaedic Surgery Vitro-Retinal Surgery

Metabolic Medicine Emergency Department Old Age Psychiatry Paediatric Physical Handicap

Nephrology Forensic Psychiatry Ophthalmology Paediatric Radiology

Neurology G.P. Medicine Oral Surgery Paediatric Respiratory Medicine

Oncology Gastro-Intestinal Surgery Orthodontics Paediatric Surgery

Palliative Medicine General Pathology Orthopaedics Paediatric Urology

Rehabilitation Medicine General Surgery Other Paediatrics

Respiratory Medicine Gynaecology Otolaryngology (ENT) Paediatrics Development

Rheumatology Hepato-Biliary Surgery Paediatric Anaesthetics Pain Relief

Spinal Paralysis Histopathology Paediatric Cardiology Pathology

Transfusion Medicine Immunology Paediatric Chem Pathology Perinatal Paediatrics

Tropical Intensive Care Paediatric Dermatology Plastic Surgery

‘Identifying’ Acute Medicine Episodes in HIPE

HIPE data manual 2017: Each row of data in HIPE represents one episode of care – one inpatient stay or a day case procedure – An episode of care begins at admission to hospital, as a day or in-patient, and ends at discharge from (or death in) that hospital. A specialty code is assigned to the record on the basis of the specialty assignment of the consultant associated with the principal diagnosis. The specialty of the consultant is the specialty in which s/he is formally recognised and contracted to work. A consultant may be formally recognised and contracted to work in more than one specialty; in these cases one specialty is recognised as the main one.

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Activity in ALL hospitals reporting to HIPE in 2017

N=1,718,524 episodes

Activity in adult acute public hospitals (n=34) in patients ≥ 16 yrs

N=1,345,990 episodes

Acute Medicine Activity – (excluding elective admissions)

N=257,189 episodes (91%); BDU=1,794,532 days (91%)

Non-Acute Medicine Activity

N=209,867 episodes (43%) BDU=1,010,276 days (34%)

Acute Medicine Activity*


Day case activity

N=854,419 episodes (64%)

In-patient activity

N=491,571(36%); BDU= 2,980,945 days

Non-AMAU activity


AMAU activity

N=93,381 episodes (36%) BDU=325,761 days (18%)

AMAU-only activity

N=58,685 episodes (63%)

AMAU-admitted activity

N=34,706 episodes (37%)

Mapping

Acute

Medicine Activity

Irish hospitals, 2017

Source: HIPE 2017, NQAIS Clinical 2017 * See slide on ‘Identifying Acute Medicine Episodes in HIPE’ 6

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0

2,000

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All AM episodes

Monthly In-patient Acute Medicine episodes, 2009-2017, adult acute hospitals (N=34)

2013 = 248,059

2017 = 281,704

2009-2012 Incomplete activity capture

This shows the monthly growth in acute medicine discharges between January 2009 and December 2017 from adult acute hospitals (n=34). It includes emergency discharges (91%) and elective discharges (9%). Incomplete data capture prior to 2012; after 2012 all episodes of care assessed in the AMAU and discharged home were recorded. Since 2013, there has been a 13.6% increase in acute medicine episodes.

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All AM episodes AM episodes- classed as emergency episodes Elective AM episodes


2009-2012 Incomplete activity capture

91%

9%

This shows the monthly growth in acute medicine discharges between January 2009 and December 2017 from adult acute hospitals (n=34). It includes emergency discharges (91%) and elective discharges (9%). Incomplete data capture prior to 2012; after 2012 all episodes of care assessed in the AMAU and discharged home were recorded. Since 2013, there has been a 13.6% increase in acute medicine episodes.

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AM episodes- classed as emergency episodes Episodes admitted from ED

Episodes admitted from Other source All epsiodes through the AMAU


2013 = 224,749 2017 = 257,189

57%

36%

7%

The dark red line (top) shows all in-patient emergency acute medicine episodes, the lines underneath show the source of admission of these episodes. in 2017, 57% of episodes were admitted from the ED, 7% admitted from ‘other source’ (predominantly outpatients) and 36% were streamed to the AMAU.

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Episodes admitted from ED Episodes admitted in-house from the AMAU

Episodes discharged home from AMAU All epsiodes through the AMAU


57%

36%

23%

13%

In terms of those streamed to the AMAU (36% of all in-patient emergency acute medicine episodes), approximately 1/3 were assessed and admitted in-house from the AMAU and the other 2/3rd s were assessed in the AMAU and discharged home from there.

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All AM episodes _bdu


2013 = 1,735,899

2017 = 1,970,669

This shows the monthly growth in bed days used by acute medicine discharges between January 2009 and December 2017 from adult acute hospitals (n=34). It includes bed days used by emergency discharges (91%) and elective discharges (9%). Since 2013, there has been a 13.5% increase in bed days used by acute medicine episodes.

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All AM episodes _bdu AM episodes- classed as emergency episodes_bdu Elective AM episodes_bdu


91%

9%

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AM episodes- classed as emergency episodes_bdu Episodes admitted from ED_bdu

All epsiodes through the AMAU_bdu Episodes admitted from Other source_bdu

72%

18%

10%

2013 = 1,575,552 2017 = 1,794,592

Bed days used (bdu) by in-patient emergency acute medicine episodes (top red line) have increased by 13.9% since 2013. In 2017, episodes admitted from the ED accounted for 72% of bed days; those streamed to the AMAU for 18% and those admitted from other sources for 10% of bed days.

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0

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Episodes admitted from ED_bdu All epsiodes through the AMAU_bdu

Episodes admitted in-house from the AMAU_bdu Episodes discharged from the AMAU_bdu

72%

18%

2%

16%

Bed days used by AMAU admissions accounted for 18% of all in-patient emergency acute medicine beds. The vast majority of this 18% was attributable to episode assessed in the AMAU and admitted in-house, while those assessed in the AMAU and discharged home only accounted for 2% of acute medicine emergency bed days.

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Year Acute

Medicine

Episodes

Episodes by length of stay category

0 days 1-3 days 4-7 days 8-14 days > 14 days

N N % N % N % N % N %

2013 248,059 57,576 23.2% 78,061 31.5% 52,720 21.3% 32,994 13% 26,708 10.8%

2014 259,316 64,710 24.9% 78,230 30.2% 53,798 20.7% 34,339 13% 28,239 10.9%

2015 264,902 65,939 24.9% 78,783 29.7% 54,861 20.7% 35,408 13% 29,911 11.3%

2016 275,695 70,559 25.6% 81,290 29.5% 57,281 20.8% 35,937 13% 30,628 11.1%

2017 281,704 69,826 24.8% 83,835 29.8% 58,978 20.9% 37,444 13% 31,621 11.2%

0

10,000

20,000

30,000

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90,000

LOS: 0 LOS: 1-3 days LOS: 4-7 days LOS: 8-14 days LOS: >14 days

Nu

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ear

2013 2014 2015 2016 2017

Source: HIPE 2013-2017. All Acute Medicine episodes (including elective admissions), all adult acute hospitals (N=34)

In 2017, 30% of AM episodes LOS of 1-3 days

The number of AM episodes have increased year on year across all length of stay categories. In 2017, over 11% of all acute medicine episodes had a LOS >14 days. This number jumps to 15% if we restrict to overnight admissions only. Almost 30% of episodes had a LOS of 1-3 days. Are these the patients that may be suited to ambulatory care?

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Designed to support services in developing and/or enhancing Ambulatory Care by identifying critical factors that should be considered when developing Ambulatory Care services. Two parts to the framework (2nd part- NAMP working with services to develop and test the critical factors for Ambulatory Care)

Mapping the data using NQAIS Clinical

I. Patient flow II. Clinical conditions managed III. Bed day usage

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1. Patient flow

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Rank by AM activity

Hospital Total AM episodes N

Total AMAU N

Total AMAU %

Non- AMAU N

Non- AMAU %

AMAU only N

AMAU only (% of AMAU)

BDU AMAU

BDU Non AMAU

Total AM BDU

Model 4 Hospitals

1 Hosp 1 14,992 4,201 28% 10,791 72% 2,903 69% 15,278 89,642 104,920

2 Hosp 2 13,639 3,640 27% 9,999 73% 2,075 57% 11,957 108,739 120,696

3 Hosp 3 13,484 4,173 31% 9,311 69% 2,404 58% 14,229 64,034 78,263

4 Hosp 4 12,982 5,185 40% 7,797 60% 3,408 66% 14,878 81,956 96,834

5 Hosp 5 12,390 NA NA 12,390 100% NA NA NA 142,372 142,372

All M4 hospitals combined 106,901 26,633 25% 80,268 75% 14,995 56% 114,873 839,925 954,798

All hospitals combined 257,189 93,381 36% 163,799 64% 58,685 63% 325,761 1,468,771 1,794,532

Flow differential of acute medical episodes (excluding electives), 2017

Patient Flow: This is an overview of Acute Medical activity at each hospital in 2017, which is provided in detail in the Ambulatory Care Framework. It presents information on the total number of AM episodes discharged from each hospital, and the numbers (and proportions) streamed through the AMAU. It also provides data on the proportion of AMAU discharges that were AMAU only (meaning admitted and discharged from AMAU only, without a further patient journey) at each hospital, and the bed days used by the admission streams under review: AMAU and non-AMAU. For example, Hospital 1 had 14,992 acute medicine in-patient discharges which were admitted as an emergency. 10,791 of these (72%) were admitted from a non-AMAU source (predominantly the ED), the remaining 28% were streamed to the AMAU. Of those seen in the AMAU, 69% were AMAU only, in that they were discharged home directly from the AMAU. There were 104,920 bed days used by these acute medicine discharges.

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Flow differential of acute medical episodes (excluding electives), 2017

28%

27% 31%

40%

0%

30%

38%

55%

80% 35% 60%

27%

41% 36% 39%

21% 26%

2% 31% 30% 48%

7% 18%

87% 78% 95%

70% 84%

100% 36%

0

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4,000

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10,000

12,000

14,000

16,000

Per

cen

tage

of

AM

ep

iso

des

str

eam

ed t

hro

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th

e A

MA

U

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cute

med

icin

e‘ in

-pat

ien

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iso

des

Accessed in the AMAU and either discharged home or admitted Admitted in-house from non-AMAU source

0 % 100

0%

Source: NQAIS Clinical 2017. In-patient Acute Medicine episodes (excluding elective admissions) 2017, adult acute hospitals (N=34)

This graphic is provide in the Ambulatory Care Framework for each of the Acute Hospitals and shows the count of in-patient Acute Medicine discharges from each hospital in 2017, and the proportion that were streamed through the AMAU (light grey) or admitted in-house from a non-AMAU source (dark grey).

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2. Mapping Acute Medicine clinical conditions & their potential for Ambulatory Care

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Mapping ICD-10-AM to CCS diagnostic codes

J39.3 Upp resp tract hypersens react site unsp 08 Respiratory 134 Upper respiratory disease other J39.8 Oth spec disease upper respiratory tract 08 Respiratory 134 Upper respiratory disease other J39.9 Disease of upper respiratory tract unsp 08 Respiratory 134 Upper respiratory disease other J40 Bronchitis not spec as acute or chronic 08 Respiratory 127 COPD & bronchiectasis J41 Simple & mucopurulent chronic bronchitis 08 Respiratory 127 COPD & bronchiectasis J41.0 Simple chronic bronchitis 08 Respiratory 127 COPD & bronchiectasis J41.1 Mucopurulent chronic bronchitis 08 Respiratory 127 COPD & bronchiectasis J41.8 Mx simple & mucopurulent chr bronchitis 08 Respiratory 127 COPD & bronchiectasis J42 Unspecified chronic bronchitis 08 Respiratory 127 COPD & bronchiectasis J43 Emphysema 08 Respiratory 127 COPD & bronchiectasis J43.0 MacLeod's syndrome 08 Respiratory 127 COPD & bronchiectasis J43.1 Panlobular emphysema 08 Respiratory 127 COPD & bronchiectasis J43.2 Centrilobular emphysema 08 Respiratory 127 COPD & bronchiectasis J43.8 Other emphysema 08 Respiratory 127 COPD & bronchiectasis J43.9 Emphysema unspecified 08 Respiratory 127 COPD & bronchiectasis J44 Other COPD 08 Respiratory 127 COPD & bronchiectasis J44.0 COPD with acute lower resp infection 08 Respiratory 127 COPD & bronchiectasis J44.1 COPD with acute exacerbation unspecified 08 Respiratory 127 COPD & bronchiectasis J44.8 Other specified COPD 08 Respiratory 127 COPD & bronchiectasis J44.9 COPD unspecified 08 Respiratory 127 COPD & bronchiectasis J45 Asthma 08 Respiratory 128 Asthma J45.0 Predominantly allergic asthma 08 Respiratory 128 Asthma J45.1 Nonallergic asthma 08 Respiratory 128 Asthma J45.8 Mixed asthma 08 Respiratory 128 Asthma J45.9 Asthma unspecified 08 Respiratory 128 Asthma J46 Status asthmaticus 08 Respiratory 128 Asthma J47 Bronchiectasis 08 Respiratory 127 COPD & bronchiectasis J60 Coalworker's pneumoconiosis 08 Respiratory 132 Lung disease external agent J61 Pneumoconiosis dt asbestos & minrl fibre 08 Respiratory 132 Lung disease external agent

ICD-10 Code_short description Major diagnoses category CCS-Clinical Classification System

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NQAIS Clinical Interface

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Top 25 Acute Medicine Clinical Conditions*, 2017

RK 1

AM

RK 2

AMAU

Primary Diagnosis CCS description

Total AM

N

% of all AM activity

Non- AMAU

N

Non- AMAU

%

Total AMAU

N

Total AMAU

%

AMAU only

N

AMAU only %

AMAU in-house

N

AMAU

in-house

%

Bed days used

% of all AM BDU

1 1 Chest pain nonspecific 16,889 6.6% 7,555 45% 9,334 55% 8,004 86% 1,330 14% 25,301 1.4%

2 5 COPD & bronchiectasis 14,824 5.8% 10,543 71% 4,281 29% 1,791 42% 2,490 58% 115,390 6.4%

3 3 Lwr respiratory infection oth 12,933 5.0% 8,395 65% 4,538 35% 2,559 56% 1,979 44% 89,569 5.0%

4 9 Pneumonia - non TB/STD 11,343 4.4% 8,822 78% 2,521 22% 555 22% 1,966 78% 124,429 6.9%

5 10 Urinary tract infection 10,492 4.1% 8,187 78% 2,305 22% 674 29% 1,631 71% 104,042 5.8%

6 4 Cardiac dysrhythmia 10,480 4.1% 5,966 57% 4,514 43% 3,257 72% 1,257 28% 34,618 1.9%

7 2 Headache 9,070 3.5% 3,336 37% 5,734 63% 4,793 84% 941 16% 15,295 0.9%

8 7 Syncope 8,648 3.4% 5,719 66% 2,929 34% 1,929 66% 1,000 34% 40,178 2.2%

9 12 Congestive heart failure 6,116 2.4% 4,145 68% 1,971 32% 624 32% 1,347 68% 61,383 3.4%

10 42 Acute myocardial infarction 5,862 2.3% 5,347 91% 515 9% 47 9% 468 91% 36,509 2.0%

11 6 Connective tissue other 5,547 2.2% 1,837 33% 3,710 67% 3,176 86% 534 14% 26,421 1.5%

12 17 Coronary atherosclerosis 5,455 2.1% 4,075 75% 1,380 25% 553 40% 827 60% 22,537 1.3%

13 18 Epilepsy 5,036 2.0% 3,815 76% 1,221 24% 649 53% 572 47% 24,656 1.4%

14 8 Conditions assoc with vertigo 4,507 1.8% 1,705 38% 2,802 62% 2,291 82% 511 18% 9,729 0.5%

15 35 Stroke ischaemic 4,431 1.7% 3,764 85% 667 15% 60 9% 607 91% 74,440 4.1%

16 28 Intestinal infection 3,979 1.5% 3,020 76% 959 24% 465 48% 494 52% 23,828 1.3%

17 11 Nervous system other 3,873 1.5% 1,864 48% 2,009 52% 1,342 67% 667 33% 22,750 1.3%

18 14 Anemia other 3,565 1.4% 1,832 51% 1,733 49% 976 56% 757 44% 18,942 1.1%

19 22 Transient cerebral ischemia 3,043 1.2% 1,965 65% 1,078 35% 519 48% 559 52% 13,064 0.7%

20 46 Sepsis agent 3,035 1.2% 2,561 84% 474 16% 35 7% 439 93% 41,030 2.3%

21 29 Diabetes with complication 2,855 1.1% 2,045 72% 810 28% 390 48% 420 52% 20,704 1.2%

22 13 Upper respiratory disease o 2,835 1.1% 1,001 35% 1,834 65% 1,605 88% 229 12% 6,514 0.4%

23 15 Lower respiratory disease o 2,669 1.0% 1,141 43% 1,528 57% 1,253 82% 275 18% 11,024 0.6%

24 21 Skin infection 2,598 1.0% 1,518 58% 1,080 42% 536 50% 544 50% 24,233 1.4%

25 36 Alcohol-related mental dis 2,373 0.9% 1,770 75% 603 25% 237 39% 366 61% 14,562 0.8%

Total (across top 25 CCS) 162,458 63.2% 101,928 63% 60,530 37% 38,320 63% 22,210 37% 1,001,136 55.8%

Total (across all CCS) 257,189 100% 163,803 64% 93,386 36% 58,655 63% 34,701 37% 1,794,532 100%

Source: NQAIS Clinical. Accessed May 2018. All Adult Acute Hospitals (n=34). * Excluding elective admissions 23


RK 1

AM

RK 2

AMAU


Total AM

N

% of all AM activity

Non- AMAU

N

Non- AMAU

%

Total AMAU

N

Total AMAU

%

AMAU only

N

AMAU only %

AMAU in-house

N

AMAU

in-house

%

Bed days used

% of all AM BDU

1 1 Chest pain nonspecific 16,889 6.6% 7,555 45% 9,334 55% 8,004 86% 1,330 14% 25,301 1.4%

2 5 COPD & bronchiectasis 14,824 5.8% 10,543 71% 4,281 29% 1,791 42% 2,490 58% 115,390 6.4%

3 3 Lwr respiratory infection oth 12,933 5.0% 8,395 65% 4,538 35% 2,559 56% 1,979 44% 89,569 5.0%

4 9 Pneumonia - non TB/STD 11,343 4.4% 8,822 78% 2,521 22% 555 22% 1,966 78% 124,429 6.9%

5 10 Urinary tract infection 10,492 4.1% 8,187 78% 2,305 22% 674 29% 1,631 71% 104,042 5.8%

6 4 Cardiac dysrhythmia 10,480 4.1% 5,966 57% 4,514 43% 3,257 72% 1,257 28% 34,618 1.9%

7 2 Headache 9,070 3.5% 3,336 37% 5,734 63% 4,793 84% 941 16% 15,295 0.9%

8 7 Syncope 8,648 3.4% 5,719 66% 2,929 34% 1,929 66% 1,000 34% 40,178 2.2%

9 12 Congestive heart failure 6,116 2.4% 4,145 68% 1,971 32% 624 32% 1,347 68% 61,383 3.4%

10 42 Acute myocardial infarction 5,862 2.3% 5,347 91% 515 9% 47 9% 468 91% 36,509 2.0%

11 6 Connective tissue other 5,547 2.2% 1,837 33% 3,710 67% 3,176 86% 534 14% 26,421 1.5%

12 17 Coronary atherosclerosis 5,455 2.1% 4,075 75% 1,380 25% 553 40% 827 60% 22,537 1.3%

13 18 Epilepsy 5,036 2.0% 3,815 76% 1,221 24% 649 53% 572 47% 24,656 1.4%

14 8 Conditions assoc with vertigo 4,507 1.8% 1,705 38% 2,802 62% 2,291 82% 511 18% 9,729 0.5%

15 35 Stroke ischaemic 4,431 1.7% 3,764 85% 667 15% 60 9% 607 91% 74,440 4.1%

16 28 Intestinal infection 3,979 1.5% 3,020 76% 959 24% 465 48% 494 52% 23,828 1.3%

17 11 Nervous system other 3,873 1.5% 1,864 48% 2,009 52% 1,342 67% 667 33% 22,750 1.3%

18 14 Anemia other 3,565 1.4% 1,832 51% 1,733 49% 976 56% 757 44% 18,942 1.1%

19 22 Transient cerebral ischemia 3,043 1.2% 1,965 65% 1,078 35% 519 48% 559 52% 13,064 0.7%

20 46 Sepsis agent 3,035 1.2% 2,561 84% 474 16% 35 7% 439 93% 41,030 2.3%

21 29 Diabetes with complication 2,855 1.1% 2,045 72% 810 28% 390 48% 420 52% 20,704 1.2%

22 13 Upper respiratory disease o 2,835 1.1% 1,001 35% 1,834 65% 1,605 88% 229 12% 6,514 0.4%

23 15 Lower respiratory disease o 2,669 1.0% 1,141 43% 1,528 57% 1,253 82% 275 18% 11,024 0.6%

24 21 Skin infection 2,598 1.0% 1,518 58% 1,080 42% 536 50% 544 50% 24,233 1.4%

25 36 Alcohol-related mental dis 2,373 0.9% 1,770 75% 603 25% 237 39% 366 61% 14,562 0.8%

Total (across top 25 CCS) 162,458 63.2% 101,928 63% 60,530 37% 38,320 63% 22,210 37% 1,001,136 55.8%

Total (across all CCS) 257,189 100% 163,803 64% 93,386 36% 58,655 63% 34,701 37% 1,794,532 100%


9/20/2018

13

366

544

275

229

420

439

559

757

667

494

607

511

572

827

534

468

1,347

1,000

941

1,257

1,631

1,966

1,979

2,490

1,330

237

536

1,253

1,605

390

35

519

976

1,342

465

60

2,291

649

553

3,176

47

624

1,929

4,793

3,257

674

555

2,559

1,791

8,004

1,770

1,518

1,141

1,001

2,045

2,561

1,965

1,832

1,864

3,020

3,764

1,705

3,815

4,075

1,837

5,347

4,145

5,719

3,336

5,966

8,187

8,822

8,395

10,543

7,555

0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000 18,000

Alcohol-related mental disorders

Skin infection

Lower respiratory disease other

Upper respiratory disease other

Diabetes with complication

Sepsis agent

Transient cerebral ischemia

Anemia other

Nervous system other

Intestinal infection

Stroke ischaemic

Conditions assoc with vertigo

Epilepsy

Coronary atherosclerosis

Connective tissue other

Acute myocardial infarction

Congestive heart failure

Syncope

Headache

Cardiac dysrhythmia

Urinary tract infection

Pneumonia - non TB/STD

Lwr respiratory infection other

COPD & bronchiectasis

Chest pain nonspecific

Assessed in the AMAU and admitted in-house Assessed in the AMAU and discharged home Admitted in-house from non-AMAU source



Top 25 Acute Medicine Clinical Conditions*, 2017 Potential for Ambulatory Care

RK 1

AM

RK 2

AMAU


Total AM

N

Total AMAU

N

Total AMAU

%

Non- AMAU

N

Non- AMAU

%

% of AMAU activity =SDD

AvLOS* AMAU

AvLOS* Non-AMAU

Total BDU AMAU

Total BDU Non AMAU

UK AEC Pot’l for AmC

Irish pathway in place

1 1 Chest pain nonspecific 16,889 9,334 55% 7,555 45% 82% 0.8 2.0 8,266 17,035 MOD YES

2 5 COPD & bronchiectasis 14,824 4,281 29% 10,543 71% 34% 4.3 6.9 21,643 93,747 LOW YES

3 3 Lower respiratory infection 12,933 4,538 35% 8,395 65% 52% 3.2 6.7 18,305 71,264 HIGH NO

4 9 Pneumonia - non TB/STD 11,343 2,521 22% 8,822 78% 16% 6.7 9.1 21,871 102,558 LOW NO

5 10 Urinary tract infection 10,492 2,305 22% 8,187 78% 24% 6.0 7.7 18,737 85,305 MOD UKN

6 4 Cardiac dysrhythmia 10,480 4,514 43% 5,966 57% 68% 1.6 3.7 7,981 26,637 MOD YES

7 2 Headache 9,070 5,734 63% 3,336 37% 79% 1.0 2.5 5,767 9,528 MOD YES

8 7 Syncope 8,648 2,929 34% 5,719 66% 58% 1.9 4.5 6,649 33,529 HIGH YES

9 12 Congestive heart failure 6,116 1,971 32% 4,145 68% 28% 6.4 9.5 14,791 46,592 MOD YES

10 42 Acute myocardial infarction 5,862 515 9% 5,347 91% 7% 6.0 5.0 3,498 33,011 N/A N/A

11 6 Connective tissue other 5,547 3,710 67% 1,837 33% 84% 1.5 8.1 6,559 19,862 *

12 17 Coronary atherosclerosis 5,455 1,380 25% 4,075 75% 33% 3.4 3.8 5,033 17,504 MOD UNK

13 18 Epilepsy 5,036 1,221 24% 3,815 76% 42% 2.2 4.0 3,493 21,163 HIGH UNK

14 8 Conditions assoc with vertigo 4,507 2,802 62% 1,705 38% 78% 1.1 3.2 3,297 6,432 HIGH YES

15 35 Stroke ischaemic 4,431 667 15% 3,764 85% 8% 11.0 12.9 8,808 65,632 N/A N/A

16 28 Intestinal infection 3,979 959 24% 3,020 76% 40% 3.3 5.0 3,821 20,007 HIGH UNK

17 11 Nervous system other 3,873 2,009 52% 1,864 48% 63% 2.5 6.0 5,991 16,759 *

18 14 Anemia other 3,565 1,733 49% 1,832 51% 51% 2.7 5.7 5,914 13,028 HIGH UNK

19 22 Transient cerebral ischemia 3,043 1,078 35% 1,965 65% 43% 2.4 4.4 2,815 10,249 HIGH YES

20 46 Sepsis agent 3,035 474 16% 2,561 84% 5% 10.1 10.4 5,933 35,097 *

21 29 Diabetes with complication 2,855 810 28% 2,045 72% 41% 3.8 6.1 3,466 17,238 HIGH UNK

22 13 Upper respiratory disease oth 2,835 1,834 65% 1,001 35% 85% 1.0 3.6 2,030 4,484 HIGH NO

23 15 Lower respiratory disease oth 2,669 1,528 57% 1,141 43% 79% 1.5 6.2 2,682 8,342 HIGH NO

24 21 Skin infection 2,598 1,080 42% 1,518 58% 47% 4.2 8.3 5,486 18,747 *

25 36 Alcohol-related mental dis 2,373 603 25% 1,770 75% 20% 3.0 4.0 2,881 11,681 *

Total (across top 25 CCS) 162,458 60,530 37% 101,928 63% 58% NA NA 195,711 805,425

Total (across all CCS) 257,189 93,386 36% 163,803 64% 58% NA NA 325,761 1,468,771


9/20/2018

14

Trimming outlying values

Source: NQAIS Clinical User Guide, Health Intelligence, Health & Wellbeing, HSE

27

Top 25 Acute Medicine Clinical Conditions* admitted to AMAU, 2017 RK 1

AM

RK 2

AMAU


Total AM

N

Total AMAU

N

Total AMAU

%

Non- AMAU

N

Non- AMAU

%


AvLOS* AMAU

AvLOS* Non-AMAU

Total BDU AMAU

Total BDU Non AMAU

UK AEC potential for AC

Irish path in place


7 2 Headache 9,070 5,734 63% 3,336 37% 79% 1.0 2.5 5,767 9,528 MOD YES

3 3 Lwr respiratory infection o 12,933 4,538 35% 8,395 65% 52% 3.2 6.7 18,305 71,264 HIGH NO




8 7 Syncope 8,648 2,929 34% 5,719 66% 58% 1.9 4.5 6,649 33,529 HIGH YES

14 8 Conditions assoc w vertigo 4,507 2,802 62% 1,705 38% 78% 1.1 3.2 3,297 6,432 HIGH YES


5 10 Urinary tract infection 10,492 2,305 22% 8,187 78% 24% 6.0 7.7 18,737 85,305 MOD UNK



22 13 Upper respiratory disease o 2,835 1,834 65% 1,001 35% 85% 1.0 3.6 2,030 4,484 HIGH NO


23 15 Lower respiratory disease o 2,669 1,528 57% 1,141 43% 79% 1.5 6.2 2,682 8,342 HIGH NO

29 16 Hypertension - essential 2,222 1,411 64% 811 36% 78% 1.0 3.0 1,550 2,810 *



34 19 Upr respiratory infection ot 1,830 1,211 66% 619 34% 85% 0.8 2.5 973 1,821 HIGH

26 20 Asthma 2,305 1,134 49% 1,171 51% 63% 1.6 3.9 2,000 5,484 LOW NO

24 21 Skin infection 2,598 1,080 42% 1,518 58% 47% 4.2 8.3 5,486 18,747 *


36 23 Thromboembolism 1,737 1,042 60% 695 40% 78% 1.4 5.3 1,588 4,310 V.HIGH YES

35 24 Viral infection 1,780 1,007 57% 773 43% 73% 1.2 3.6 1,449 3,242 *

31 25 Residual codes - unclasssif 2,142 1,005 47% 1,137 53% 68% 2.7 7.0 3,095 12,521 *




9/20/2018

15

Top 25 Acute Medicine Clinical Conditions* admitted to AMAU, 2017 RK 1

AM

RK 2

AMAU


Total AM

N

Total AMAU

N

Total AMAU

%

Non- AMAU

N

Non- AMAU

%


AvLOS* AMAU

AvLOS* Non-AMAU

Total BDU AMAU

Total BDU Non AMAU

UK AEC potential for AC

Irish path in place


7 2 Headache 9,070 5,734 63% 3,336 37% 79% 1.0 2.5 5,767 9,528 MOD YES

3 3 Lwr respiratory infection o 12,933 4,538 35% 8,395 65% 52% 3.2 6.7 18,305 71,264 HIGH NO




8 7 Syncope 8,648 2,929 34% 5,719 66% 58% 1.9 4.5 6,649 33,529 HIGH YES

14 8 Conditions assoc w vertigo 4,507 2,802 62% 1,705 38% 78% 1.1 3.2 3,297 6,432 HIGH YES


5 10 Urinary tract infection 10,492 2,305 22% 8,187 78% 24% 6.0 7.7 18,737 85,305 MOD UNK



22 13 Upper respiratory disease o 2,835 1,834 65% 1,001 35% 85% 1.0 3.6 2,030 4,484 HIGH NO


23 15 Lower respiratory disease o 2,669 1,528 57% 1,141 43% 79% 1.5 6.2 2,682 8,342 HIGH NO

29 16 Hypertension - essential 2,222 1,411 64% 811 36% 78% 1.0 3.0 1,550 2,810 *



34 19 Upr respiratory infection ot 1,830 1,211 66% 619 34% 85% 0.8 2.5 973 1,821 HIGH

26 20 Asthma 2,305 1,134 49% 1,171 51% 63% 1.6 3.9 2,000 5,484 LOW NO

24 21 Skin infection 2,598 1,080 42% 1,518 58% 47% 4.2 8.3 5,486 18,747 *


36 23 Thromboembolism 1,737 1,042 60% 695 40% 78% 1.4 5.3 1,588 4,310 V.HIGH YES

35 24 Viral infection 1,780 1,007 57% 773 43% 73% 1.2 3.6 1,449 3,242 *

31 25 Residual codes - unclasssif 2,142 1,005 47% 1,137 53% 68% 2.7 7.0 3,095 12,521 *



Source: NQAIS Clinical. Accessed May 2018. All Adult Acute Hospitals (n=34). * Excluding elective admissions

Analysis conducted for: 1. All adult acute hospitals combined (aged≥16

years) 2. Hospitals grouped by Model type 3. Adult aged ≥ 75 years 4. Adults aged ≥ 75 years, grouped by Model type 5. Individually for 32/34 adult acute hospitals

29

3. A focus on the three common clinical conditions and assessing their potential for Ambulatory Care

1. Chest pain - non-specific

2. Lower Respiratory Infection Other

3. COPD & Bronchiectasis

30

9/20/2018

16

Lower Respiratory Infection Other

• J20 Acute bronchitis

– J20.0 Ac bronchitis dt Mycoplasma pneumoniae – J201 Ac bronchitis dt Haemophilus influenzae – J20.2 Acute bronchitis due to streptococcus – J20.3 Acute bronchitis due to coxsackievirus – J20.4 Acute bronchitis dt parainfluenza virus – J20.5 Ac bronchitis dt resp syncytial virus J206 Acute bronchitis due to rhinovirus – J20.7 Acute bronchitis due to echovirus – J20.8 Acute bronchitis dt other spec organisms – J20.9 Acute bronchitis unspecified J21 Acute bronchiolitis

• J21 Acute bronchiolitis

– J21.0 Ac bronchiolitis dt resp syncytial virus – J21.1Ac bronchiolitis dt human metapneumovirus – J21.8 Ac bronchiolitis dt other spec organisms – J21.9 Acute bronchiolitis unspecified

• J22 Unspecified acute lower respiratory infection - 98.5% episodes

31

26%

29%

32%

28% 39%

39%

35%

21%

30%

42% 16%

63%

20% 82%

59%

45%

24% 1%

19% 47%

7%

7%

76% 92%

63% 92%

56%

0

100

200

300

400

500

600

700

800

900

Per

cen

tage

of

AM

Ep

iso

des

str

eam

ed t

hro

ugh

th

e A

MA

U

Nu

mb

er o

f 'a

cute

med

icin

e’ in

-pat

ien

t ep

iso

des

Accessed in the AMAU and either discharged home or admitted Admitted in-house from non-AMAU source

100

100%

35%

This graphic is provide in the Ambulatory Care Framework for each of the Acute Hospitals and shows the count of in-patient discharges with a primary diagnosis of lower resp infection (other) from each hospital in 2017, and the proportion that were streamed through the AMAU (light grey) or admitted in-house form a non-AMAU source (dark grey).

Lower Respiratory Infection Other, 3rd most common CCS, 2017

Median age=73 years; IQR 59-83 yrs Source: NQAIS Clinical. Accessed May 2018. All Adult Acute Hospitals (n=34). * Excluding elective admissions

32

9/20/2018

17

Hospital Total episodes

AMAU N

AMAU %

Non- AMAU N

Non- AMAU %

% of AMAU activity =AMAU only


AvLOS All epis

AvLOS* All epis

AvLOS* AMAU

AvLOS* Non- AMAU

BDU AMAU

BDU Non-AMAU

Total AM BDU

Model 4 Hospitals

1 Hosp 1 725 186 26% 539 74% 55% 51% 8.4 6 4 6.8 968 5,120 6,088

3 Hosp 2 599 174 29% 425 71% 49% 48% 5.2 4.8 3.7 5.3 673 2,453 3,126

4 Hosp 3 556 NA NA 556 100% NA NA 12.9 7.9 NA 7.9 NA 7,163 7,163

All M4 combined 4,052 916 23% 3,136 77% 53% 44% 9.1 6.2 3.5 7.0 4,923 32,040 36,963

All hospitals combined

12,933 4,538 35% 8395 65% 56% 52% 6.9 5.4 3.2 6.7 18,305 71,264 89,569

Lower Respiratory Infection Other

This is an overview of in-patient epsiodes with a primary diagnosis of lower respiratory infection (other) discharged from acute hospitals in 2017. This is provided in detail in the Ambulatory Care Framework. It presents information on the total number of these episodes discharged from each hospital, and the numbers (and proportions) streamed through the AMAU. It also provides data on the proportion of AMAU discharges that were AMAU only (meaning admitted and discharged from AMAU only, without a further patient journey) at each hospital, or AMAU SDD (same day discharge from the AMAU ). Also presented are details of the average length of stay in each hospital of these episodes and the average length of stay after trimming outlying values. Data on bed days used by the admission streams under review: AMAU and non-AMAU is also presented. Across all acute hospitals in 2017, there were almost 13,000 episodes admitted with a primary diagnosis of lower respiratory infection other of which 35% were streamed through he AMAU. For example, Hospital 1 had 725 in-patient episodes with a primary diagnosis of lower respiratory infection other discharged in 2017. Of these episodes 26% were streamed through the AMAU, 74% were admitted in-house from a non-AMAU source, predominantly the ED. Of those streamed into the AMAU, 55% were AMAU only, in that they completed their journey in the AMAU; 51% did so ion the same day as admission. The average length of stay across all admission sources was 8.4 days; the trimmed value was 6 days. Those that were admitted to the AMAU ( and either discharged home or admitted in-house) had an average length of stay of 4 days; those admitted as an in-patient from non-AMAU sources had a length of stay of 6.8 days.

33

Lower Respiratory Infection, Other

3.5

2.6

4.2

0

1

2

3

4

5

6

Ave

rage

len

gth

of

stay

per

ho

spit

al

Average length of stay (trimmed) of all episodes of care through the AMAU

Model 4 hospitals Model 3 hospitals Model 2 hospitals 34

9/20/2018

18

Potential for Ambulatory Care? Lower Respiratory Infection, other

‘Lower Respiratory Infection, other’ should be considered a high probability for conversion to Ambulatory Care.

• The UK AEC directory has placed it as having between 60-90% Ambulatory

sensitive.

• Currently those patients moving through AMAUs have an ALOS of 3.2 days (trimmed)

• For approx 13,000 episodes in 2017, the bed day usage overall was almost 90,000

Therefore there is significant saving in capacity to be made by addressing the management of this condition.

35

Potential for Ambulatory Care? Chest pain non-specific

There is a substantial opportunity for converting this condition to Ambulatory

Care.

• Across all hospitals the current ALOS is less than 2 days. Many hospitals already

have high levels of same day discharge for patients with this primary diagnosis which indicates that is likely that accessibility of diagnostics may be a potential solution for full conversion.

• It is also worth considering the possibility that patients could be ambulated over 24-48 hours rather than being admitted as an inpatient to await procedures or tests which they may safely have as a day patient.

36

9/20/2018

19

Potential for Ambulatory Care? COPD & bronchiectasis

Based on the 2017 figures it is not realistic to consider COPD & Bronchiectasis

admissions in Irish hospitals to be converted to Ambulatory Care in the short term.

• In response to this work, the National Clinical Programme for COPD advises that “appropriately functioning outreach services for COPD patients can assist in hospital avoidance and improve overall length of stay for inpatients with COPD.”

– They recommend that hospitals with existing COPD outreach services should ensure they are utilised fully to increase the potential for admission avoidance and supportive discharge.

– It is also recommended that acute hospitals that do not currently have COPD outreach services should consider their establishment for the effective and appropriate management of patients with COPD who do not require acute admission or will benefit from early supported discharge.

37

Documents

Using data to inform the development of Ireland’s ...Ireland’s Ambulatory Care Framework Eimir Hurley BSc (Pharm) MBiostat, PhD Scholar in Health Services Research ... Cardiology