Analysis of Trends in Emergency Admissions in E l d 2004 2009England 2004‐2009
Ian BluntIan BluntSenior Research Analyst
www.nuffieldtrust.org.uk
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
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
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
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.
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
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
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.
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
Is the increase related to age?
Has the case mix of emergency admission changed?changed?
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
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
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)
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)
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)
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)
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
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
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
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
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