Follow up of people aged 65 and over with a history of emergency admis
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《英国医生杂志》
1 National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, 2 National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO1 5DD, 3 Sheffield Institute for Studies of Ageing, University of Sheffield, Sheffield S5 7AU
Correspondence to: M Roland m.roland@man.ac.uk
Abstract
Efforts to improve the effectiveness and efficiency of health services often focus on reducing inpatient stays, the most expensive element of health care. A systematic review found that integrated care experiments in elderly people could reduce rates of admission, though the effects are highly dependent on the system of care and the nature of the intervention.1 Case management of patients at risk of admission has also been proposed as a way of reducing the risk of readmission, but a recent review found only limited evidence that this approach reduces use of health services.2
One way of identifying patients at risk of admission is to select those with recent emergency or unscheduled admissions. Published risk assessment tools identify past admissions, especially unscheduled admissions, as important risk factors for subsequent admission.3-5 For example, a history of two or more emergency admissions in the previous year is the principle factor used to identify patients to enrol in an intensive case management programme for older people currently being introduced in the United Kingdom by Evercare,6 an arm of the US healthcare provider United Health Group. This initiative uses specially trained nurses to monitor vulnerable older people at home and is modelled on similar Evercare interventions in the United States7 that are associated with reduced risk of readmission to hospital.8
Evercare is not alone in using history of unplanned admissions as a means of identifying patients at risk of future admission. The same approach has been used as the entry criterion for several trials9-11 and as one of the criteria for case management in the new NHS policy on long term conditions.12
Sometimes, outcomes of interventions are assessed purely in terms of reduction in admissions among a cohort of older people without any reference to a control group, the assumption being that patients identified at high risk on the basis of their previous admissions would continue to be at high risk of admission in the absence of the intervention.
Since April 1997, administrative data have been available in England that make it possible to track emergency admission patterns of individual patients. We used these data to establish the natural history of emergency admissions and bed use of older patients with a history of multiple unscheduled admissions.
Method
The table and figure show that the total admissions and bed days for older people with a history of two or more unscheduled admissions in an index year decreased sharply in subsequent years (table). Members of the high risk cohort aged 65-74 had an admission rate in the index year 1997-8 that was 20 times greater than the rate in the general population of the same age. The ratio fell to 5.2 in 1998-9 and 1.7 in 2002-3. For the oldest members of the high risk cohort (aged 85 in 1997-8) the ratio of their admission rate to that of the general population of the same age fell from 5.9 in the index year to 1.6 in the following year and to 0.53 in 2002-3.
Emergency admissions and bed days per head for patients aged 65, 65-74, 75-84, and 85 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 with general population (England)
Emergency admissions and emergency bed days per person for patients 65 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 ("high risk") with general population (England)
The 1997-8 high risk cohort was 2.9% of the total English population aged 65 in mid-1997. The share of emergency admissions of those aged 65 in 1997-8 accounted for by the 1997-8 high risk cohort fell from 38.2% in 1997-8 to 9.9% in the following year and to 3.2% by 2002-3.
Of the 223 993 patients aged 66 who had two or more emergency admissions in 1998-9, 30 020 had had two or more emergency admissions in the previous year (1997-8). Thus the sensitivity of the criteria of being 65 and having at least two admissions in 1997-8 in detecting patients age 66 who would have two or more admissions in the following year (1998-9) was 13.4%.
Discussion
Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. Int J Geriatr Psychiatry 2003;18: 222-35.
Hutt R, Rosen R, McCauley J. Case managing long term conditions. London: King's Fund, 2004.
Pacala JT, Boult C, Boult L. Predictive validity of a questionnaire that identifies older persons at risk of hospital admission. J Am Geriatr Soc 1995;43: 374-7.
Brody KK, Johnson RE, Ried LD, Carder PC, Perrin N. A comparison of two methods for identifying frail Medicare aged persons. J Am Geriatr Soc 2002;50: 562-9.
Meldon SW, Mion LC, Palmer RM, Drew BL, Connor JT, Lewiwicki LJ, et al. A brief risk stratification tool to predict repeat emergency department visits and hospitalisations in older patients discharged from the emergency room. Acad Emerg Med 2003;10: 224-32.
Implementing the Evercare Programme. Interim report. February 2004. www.natpact.nhs.uk/cms/186.php (accessed 14 Jan 2005).
www.evercareonline.com/products/products.html (accessed 14 Jan 2005).
Kane R, Keckhafer G, Flood S, Bershadsky B, Siadaty M. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51: 1427-34.
Brook GM, Reuben D, Zendle LJ, Ershoff DH, Wolde-Tsadik G, Rubenstein LZ, et al. Rationale and design of a multi-centre randomized trial of comprehensive geriatric assessment consultation for hosptializes patients in an HMO. J Am Geriatr Soc 1994;42: 536-44.
Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 1998;158: 1067-72.
Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. J Gen Intern Med 1993;8: 585-90.
Department of Health. Supporting people with long term conditions. London: Department of Health, 2005. www.dh.gov.uk/PublicationsAndStatistics/Pub lications/PublicationsPolicyAndGuidance/Publications PolicyAndGuidanceArticle/fs/en (accessed 14 Jan 2005).
Boaden R, Dusheiko M, Gravelle H, Parker S, Pickard S, Roland M, et al. Evercare evaluation interim report: implications for supporting people with long term conditions. Manchester: National Primary Care Research and Development Centre, University of Manchester. www.npcrdc.man.ac.uk/ResearchDetail.cfm?ID=131&status=In%20Progress&theme=3
Office for National Statistics. Mid-1997 population estimates: England; single year of age and sex; estimated resident population, revised (03/06/04) in light of the results of the 2001 Census. London: Office for National Statistics. www.statistics.gov.uk/ (accessed 14 Jan 2005).
Ashton C, Wray NP. A conceptual framework for the study of early readmission as an indicator of quality of care. Soc Sci Med 1996;43: 1533-41.
Clarke A. Readmission to hospital: a measure of quality or outcome? Qual Saf Health Care 2004;13: 10-1.
Basu J, Friedman B, Burstin H. Primary care, HMO enrolment, and hospitalization for ambulatory sensitive conditions. Med Care 2002;40: 1260-9.
Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T. Hospitalisation rates as indicators of access to primary care. Health Place 2001;7: 27-38.
Giuffrida A, Gravelle H, Roland M. Measuring quality with routine data: avoiding confusion between performance indicators and health outcomes. BMJ 1999;319: 94-8.
Leng GC, Walsh D, Fowkes FGR, Swainson CP. Is the emergency readmission rate a valid outcome indicator? Qual Health Care 1999;8: 234-8.
Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy 2000;5: 222-30.(Martin Roland, director1, Mark Dusheiko,)
Correspondence to: M Roland m.roland@man.ac.uk
Abstract
Efforts to improve the effectiveness and efficiency of health services often focus on reducing inpatient stays, the most expensive element of health care. A systematic review found that integrated care experiments in elderly people could reduce rates of admission, though the effects are highly dependent on the system of care and the nature of the intervention.1 Case management of patients at risk of admission has also been proposed as a way of reducing the risk of readmission, but a recent review found only limited evidence that this approach reduces use of health services.2
One way of identifying patients at risk of admission is to select those with recent emergency or unscheduled admissions. Published risk assessment tools identify past admissions, especially unscheduled admissions, as important risk factors for subsequent admission.3-5 For example, a history of two or more emergency admissions in the previous year is the principle factor used to identify patients to enrol in an intensive case management programme for older people currently being introduced in the United Kingdom by Evercare,6 an arm of the US healthcare provider United Health Group. This initiative uses specially trained nurses to monitor vulnerable older people at home and is modelled on similar Evercare interventions in the United States7 that are associated with reduced risk of readmission to hospital.8
Evercare is not alone in using history of unplanned admissions as a means of identifying patients at risk of future admission. The same approach has been used as the entry criterion for several trials9-11 and as one of the criteria for case management in the new NHS policy on long term conditions.12
Sometimes, outcomes of interventions are assessed purely in terms of reduction in admissions among a cohort of older people without any reference to a control group, the assumption being that patients identified at high risk on the basis of their previous admissions would continue to be at high risk of admission in the absence of the intervention.
Since April 1997, administrative data have been available in England that make it possible to track emergency admission patterns of individual patients. We used these data to establish the natural history of emergency admissions and bed use of older patients with a history of multiple unscheduled admissions.
Method
The table and figure show that the total admissions and bed days for older people with a history of two or more unscheduled admissions in an index year decreased sharply in subsequent years (table). Members of the high risk cohort aged 65-74 had an admission rate in the index year 1997-8 that was 20 times greater than the rate in the general population of the same age. The ratio fell to 5.2 in 1998-9 and 1.7 in 2002-3. For the oldest members of the high risk cohort (aged 85 in 1997-8) the ratio of their admission rate to that of the general population of the same age fell from 5.9 in the index year to 1.6 in the following year and to 0.53 in 2002-3.
Emergency admissions and bed days per head for patients aged 65, 65-74, 75-84, and 85 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 with general population (England)
Emergency admissions and emergency bed days per person for patients 65 in 1997-8: comparison of those with two or more emergency admissions in 1997-8 ("high risk") with general population (England)
The 1997-8 high risk cohort was 2.9% of the total English population aged 65 in mid-1997. The share of emergency admissions of those aged 65 in 1997-8 accounted for by the 1997-8 high risk cohort fell from 38.2% in 1997-8 to 9.9% in the following year and to 3.2% by 2002-3.
Of the 223 993 patients aged 66 who had two or more emergency admissions in 1998-9, 30 020 had had two or more emergency admissions in the previous year (1997-8). Thus the sensitivity of the criteria of being 65 and having at least two admissions in 1997-8 in detecting patients age 66 who would have two or more admissions in the following year (1998-9) was 13.4%.
Discussion
Johri M, Beland F, Bergman H. International experiments in integrated care for the elderly: a synthesis of the evidence. Int J Geriatr Psychiatry 2003;18: 222-35.
Hutt R, Rosen R, McCauley J. Case managing long term conditions. London: King's Fund, 2004.
Pacala JT, Boult C, Boult L. Predictive validity of a questionnaire that identifies older persons at risk of hospital admission. J Am Geriatr Soc 1995;43: 374-7.
Brody KK, Johnson RE, Ried LD, Carder PC, Perrin N. A comparison of two methods for identifying frail Medicare aged persons. J Am Geriatr Soc 2002;50: 562-9.
Meldon SW, Mion LC, Palmer RM, Drew BL, Connor JT, Lewiwicki LJ, et al. A brief risk stratification tool to predict repeat emergency department visits and hospitalisations in older patients discharged from the emergency room. Acad Emerg Med 2003;10: 224-32.
Implementing the Evercare Programme. Interim report. February 2004. www.natpact.nhs.uk/cms/186.php (accessed 14 Jan 2005).
www.evercareonline.com/products/products.html (accessed 14 Jan 2005).
Kane R, Keckhafer G, Flood S, Bershadsky B, Siadaty M. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51: 1427-34.
Brook GM, Reuben D, Zendle LJ, Ershoff DH, Wolde-Tsadik G, Rubenstein LZ, et al. Rationale and design of a multi-centre randomized trial of comprehensive geriatric assessment consultation for hosptializes patients in an HMO. J Am Geriatr Soc 1994;42: 536-44.
Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med 1998;158: 1067-72.
Rich MW, Vinson JM, Sperry JC, Shah AS, Spinner LR, Chung MK, et al. Prevention of readmission in elderly patients with congestive heart failure: results of a prospective, randomized pilot study. J Gen Intern Med 1993;8: 585-90.
Department of Health. Supporting people with long term conditions. London: Department of Health, 2005. www.dh.gov.uk/PublicationsAndStatistics/Pub lications/PublicationsPolicyAndGuidance/Publications PolicyAndGuidanceArticle/fs/en (accessed 14 Jan 2005).
Boaden R, Dusheiko M, Gravelle H, Parker S, Pickard S, Roland M, et al. Evercare evaluation interim report: implications for supporting people with long term conditions. Manchester: National Primary Care Research and Development Centre, University of Manchester. www.npcrdc.man.ac.uk/ResearchDetail.cfm?ID=131&status=In%20Progress&theme=3
Office for National Statistics. Mid-1997 population estimates: England; single year of age and sex; estimated resident population, revised (03/06/04) in light of the results of the 2001 Census. London: Office for National Statistics. www.statistics.gov.uk/ (accessed 14 Jan 2005).
Ashton C, Wray NP. A conceptual framework for the study of early readmission as an indicator of quality of care. Soc Sci Med 1996;43: 1533-41.
Clarke A. Readmission to hospital: a measure of quality or outcome? Qual Saf Health Care 2004;13: 10-1.
Basu J, Friedman B, Burstin H. Primary care, HMO enrolment, and hospitalization for ambulatory sensitive conditions. Med Care 2002;40: 1260-9.
Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T. Hospitalisation rates as indicators of access to primary care. Health Place 2001;7: 27-38.
Giuffrida A, Gravelle H, Roland M. Measuring quality with routine data: avoiding confusion between performance indicators and health outcomes. BMJ 1999;319: 94-8.
Leng GC, Walsh D, Fowkes FGR, Swainson CP. Is the emergency readmission rate a valid outcome indicator? Qual Health Care 1999;8: 234-8.
Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy 2000;5: 222-30.(Martin Roland, director1, Mark Dusheiko,)