Preventable Hospitalizations and Access to Health Care

Bindman, Andrew B.; Grumbach, Kevin; Osmond, Dennis; Komaromy, Miriam; Vranizan, Karen; Lurie, Nicole; Billings, John; Stewart, Anita L.

doi:10.1001/jama.1995.03530040033037

Cited by 726 publications

(464 citation statements)

References 9 publications

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“…Our findings are therefore limited to COPD and asthma, and may not be generalisable to other LTCs. 20,[182][183][184] However, the decision-making process that patients with LTCs use to determine whether or not to use unscheduled care is unclear.…”

Section: Discussionmentioning

confidence: 99%

CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie

Afzal

Blakeley

et al. 2017

Programme Grants Appl Res

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BackgroundOver 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.ObjectivesThe aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).DesignA three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.SettingPrimary care. Manchester and London.ParticipantsPeople aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.ResultsEvidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.LimitationsThe findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.ConclusionsPrior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.Future workThe potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

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Section: Discussionmentioning

confidence: 99%

CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie

Afzal

Blakeley

et al. 2017

Programme Grants Appl Res

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“…5 Another metaanalysis found that 68% of patients who committed suicide did not have contact with mental health services in the year before suicide. 4 The association between decreased ambulatory treatment of NPPDs and SUDs and hospitalization remains unknown, although this has been well established for chronic medical conditions, 12 and there is no reason to think that it would not apply to mental disorders. It is currently unknown whether shortening the period of untreated illness would result in reduced health care expenditures, morbidity, and mortality; however, the association between lack of care and greater mortality related to suicide and overdose suggests the need for interventions to improve active care of psychiatric conditions.…”

Section: The Association Of Untreated Illness With Morbidity and Mortmentioning

confidence: 99%

Duration and Relevance of Untreated Psychiatric Disorders, 2: Nonpsychotic Psychiatric Disorders and Substance Use Disorders

Rubio¹,

Correll²

2017

J. Clin. Psychiatry

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“…Based on a sample of 6000 full ED records, the algorithm classifies visits on the basis of discharge diagnosis as 1) non-emergent, 2) emergent/primary care treatable, 3) emergent -ED care needed -preventable/avoidable and 4) emergent -ED care needed -not preventable/avoidable. [24,25] ED visits resulting in discharge rather than admission was…”

Section: Literature Searchmentioning

confidence: 99%

Defining potentially preventable emergency department visits for older adults

Latham

Ackroyd‐Stolarz

2017

IJH

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Objective: As older adults become increasingly reliant on emergency departments (EDs) for care, there is an interest in determining what types of ED visits by this population may be preventable, or amenable to other forms of care. The aim of this project was to explore the concept of preventable ED visits by older adults. Methods: We conducted a literature search to identify definitions of "preventable" or "avoidable" ED visits. We then applied a definition of preventable ED visits to an administrative data set consisting of ED visit data extracted from four sites in Halifax, Nova Scotia, Canada. Visits for patients 65 years of age or older were eligible for inclusion. Visits were categorized using triage level and discharge diagnosis. Results: Four methods of defining preventable ED visits were identified in our literature search: 1) Ambulatory Care Sensitive Conditions (ACSCs) (N = 7), 2) Low Acuity/low intensity visits (N = 5), 3) New York University (NYU) (Billings) Algorithm (N = 3) and 4) hospital admission vs. non-admission (N = 1). We categorized 34,454 ED visits from our dataset using a modified definition of preventable ED visits that included ACSCs (15.3%) as well as low acuity visits that required no testing or hospital admission (9.9%). Conclusions: Our results suggest that approximately 25% of ED visits by older adults may be preventable or amenable to other forms of care. This data may be useful in the planning of care delivery appropriate for the needs of this population.

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Preventable Hospitalizations and Access to Health Care

Cited by 726 publications

References 9 publications

CHOICE: Choosing Health Options In Chronic Care Emergencies

CHOICE: Choosing Health Options In Chronic Care Emergencies

Duration and Relevance of Untreated Psychiatric Disorders, 2: Nonpsychotic Psychiatric Disorders and Substance Use Disorders

Defining potentially preventable emergency department visits for older adults

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