No abstract

Objective To determine the subsequent pattern of emergency admissions in older people with a history of frequent emergency admissions. Design Analysis of routine admissions data from NHS hospitals using hospital episode statistics (HES) in England. Subjects Individual patients aged ≥ 65, ≥ 75, and ≥ 85 who had at least two emergency admissions in 1997-8. Main outcome measures Emergency admissions and bed use in this "high risk" cohort of patients were counted for the next five years and compared with the general population of the same age. No account was taken of mortality as the analysis was designed to estimate the future use of beds in this high risk cohort. Results Over four to five years, admission rates and bed use in the high risk cohorts fell to the mean rate for older people. Although patients ≥ 65 with two or more such admissions were responsible for 38% of admissions in the index year, they were responsible for fewer than 10% of admissions in the following year and just over 3% five years later. Conclusion Patients with multiple emergency admissions are often identified as a high risk group for subsequent admission and substantial claims are made for interventions designed to avoid emergency admission in such patients. Simply monitoring admission rates cannot assess interventions designed to reduce admission among frail older people as rates fall without any intervention. Comparison with a matched control group is necessary. Wider benefits than reduced admissions should be considered when introducing intensive case management of older people.

Objective To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).Design Controlled longitudinal study.Setting English National Health Service between 1998/99 and 2010/11. Participants Populations registered with each of 6975 family practices in England.Main outcome measures Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.Results Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. ConclusionsThe introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

No abstract