Reductions in hospital admissions and mortality rates observed after integrating emergency care: a natural experiment

Abstract

ObjectivesReducing emergency admissions is a priority for the NHS. A single hospital's emergency care system was reorganised with the principles of front-loaded investigations, integration of specialties, reduced duplication, earlier decision making by senior clinicians and a combined emergency assessment area. The authors relocated our Medical Assessment Unit into our emergency department in 2006. The authors evaluated changes in admissions and mortality before and after 2006, compared with other similar hospitals.DesignQuasi-experimental before and after study using routinely collected data.Setting and participants1 acute hospital in England, the intervention site, was compared with 23 other English hospitals between 2001 and 2009.Outcome measuresOur outcome measures were hospital standardised mortality ratios (HSMRs) for non-elective admissions and standardised admission ratios (SARs).ResultsThe authors observed a statistically and clinically significant decrease in HSMR and SAR. The intervention hospital had the lowest HSMR and SAR of all the hospitals in our sample. This was statistically significant, p=0.0149 and p=0.0002, respectively.ConclusionIntegrating emergency care in one location is associated with a meaningful reduction in mortality and emergency admissions to hospital.

Clinical frailty adds to acute illness severity in predicting mortality in hospitalized older adults: An observational study

“…Our study has important limitations, including its single center perspective and the relatively small number of deaths despite a large initial sample size, a problem that was significantly aggravated by missing data. The overall 30-day inpatient mortality proportion was 6.7% (548 deaths), which is comparable to overall inpatient mortality rates in England for this older age group [26,27]. However, due to our proportion of missing data, we were unable to study 238 out of 548 deaths in the database, with consequent underpower.…”

Understanding new models of integrated care in developed countries: a systematic review

“…Appendix 2 contains these assessments. For the UK literature, 16 studies 39,42,44,45,48,52,54,58,63,74,77,78,81,82,85,86 used higher-quality comparator designs. Of these studies, only two 58,63 had utilised some form of random allocation to condition, and the nature of the intervention precluded allocation concealment within studies.…”

“…Intervention studies from the UK have reported a reduction in the number of unscheduled admissions of 22%, 37 a 16.3% decrease in the number of emergency medical admissions and a 3.9% decrease in the number of emergency surgical admissions, 40 17 admissions for 13 patients, 47 a 2% reduction for multiple admitters, 54,66 a reduction from 935 to 840 admissions in a year for COPD patients, 72 and a significant effect size following a service reconfiguration compared with other hospitals (p = 0.0002). 39 None of these studies was of comparator design.…”

“…Studies report conflicting findings regarding the effect on readmission rates, with three UK studies reported in four papers 36,38,39,54 (including one study with a comparator group 54 ) indicating no significant effect on (1) older at-risk patients, 54 (2) patients originally admitted as emergencies 38,39 or (3) patients with COPD following a hospital at home intervention, service reconfiguration or a case management intervention. 36 Two studies indicated an increase in readmissions, 69,82 although one of these 69 was of very poor quality.…”

“…One UK non-comparator study 71 reported that the frequency of aggressive incidents among inpatients with mental health and behaviour problems was reduced following the introduction of an integrated assessment and treatment service. Another UK before-and-after study 39 reported that numbers of formal complaints, incident reports and patients leaving before treatment declined following service redesign and the establishment of an integrated emergency assessment unit.…”