How many emergency admissions can primary care policies actually prevent? Answer: Not many.

Emergency admissions, as well as the obvious effect on the patient, family and carers, cost a lot. In 2012, they cost the NHS over £12.5 billion, so understandably there is a desire to contain these costs as they may be better spent elsewhere.

A good number of these admissions will be unavoidable and the NHS can do nothing to prevent them: people will always break bones, get nasty infections and have other emergencies and episodes which result in unexpected admission to hospital. However, in theory, a well-managed patient with chronic disease such as diabetes, heart disease or asthma (so-called ‘ambulatory sensitive care’ or ASC conditions), should not be turning up at A&E or spending time in hospital, at least not for reasons related to their chronic disease. Thus emergency admissions for ASC conditions make a useful quality indicator for primary care. In fact, in England, GPs are incentivised to identify the top 2% of their practice population at highest risk of emergency admission.

But how good are the existing tools at identifying those at risk and what can be done with them? In a paper in today’s BMJ, CCHSR’s Martin Roland along with colleagues from the Royal College of Surgeons in Ireland looked at two of the best performing tools to see what effect they may have on a typical GP practice.

Using the tools, the top 1.6-1.7% of patients at risk are responsible for around 10-14% of all emergency admissions. In a GP practice of 10,000 patients this means 160 patients are expected to have 95 emergency admissions between them over the next year. Around 20% of all emergency admissions are due to ASC conditions and thus may be preventable, or 19 of our 95 admissions. But disease management programmes aren’t perfect. In fact they only prevent around 18% of ASC admissions. 18% of the 19 is around 4 emergency admissions per year.

So using the best risk prediction tools available to identify the most at-risk patients, and implementing the best disease management programme for those patients means a GP practice of 10,000 patients could prevent only 4 emergency admissions per year. Is such an approach the best use of a busy GP’s time? In other words, is it cost-effective? The authors suggest such a blanket approach is perhaps not, and rather than simply incentivising a practice to identify all patients at most risk of emergency admission, a shift in focus targeting specific ASC conditions as well as end of life care may be more effective and cost-effective.

 

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  • The Cambridge Centre for Health Services Research (CCHSR) is a thriving collaboration between the University of Cambridge and RAND Europe. We aim to inform health policy and practice by conducting research and evaluation studies of organisation and delivery of healthcare, including safety, effectiveness, efficiency and patient experience.