From April 2014 a large amount of money has been committed to the DES for unplanned admissions in England, while the risk profiling DES has been withdrawn and the QOF has been scaled down. Contract changes in Wales and Scotland have a similar theme.
The basis for this is that the number of unplanned admissions is increasing year-by-year in the UK and that hospitals are being swamped in providing acute care. Theoretically if we improve care for people likely to get admitted acutely, and develop different models of care for them with improved integrated services in the community, we can avoid these admissions. However, it has been argued that the evidence that these approaches work or are cost-effective is poor and that the premise for the new DES is weak.1
Whatever these concerns, it seems worthy to set up systems to co-ordinate and enhance healthcare and community and social services for patients likely to need acute hospital admissions, simply because these patients need greater continuity of care and more intensive support and hopefully this input should make life better for them.
The exact means by which the 2% of the adult population, as described in the DES, can be identified as likely to have an unplanned admission using ‘risk profiling’ and become the subject of ‘case management registers’ and ‘personalised care planning’ with a ‘named accountable GP’ has not yet been specified.
In Scotland a lot of work has gone into ‘SPARRA’ (Scottish Patients at Risk of Readmission and Admission score), a data extraction tool that can be run on computer databases to help predict which patients are at high risk of admission or readmission.1 Similar work has gone into the development of the QAdmissions score using the UK QResearch GP database, and this may form the basis for risk stratification for the English DES.3
Until the exact detail emerges on the use of risk stratification tools, common sense alongside the information provided by the research into developing these tools, and the evidence of the types of patients and conditions where unplanned admissions are common, provide useful pointers to the profiles of patients suitable for case management and for greater clinical input. It seems sensible to get to work on enhancing care for these people in anticipation of the detail.
This article covers five examples of types of patients for whom unplanned admission is more likely.
1 Patients who have had two or more unplanned admissions in the last year for a long-term or persistent condition
Patients with LTCs or chronics conditions who’ve had emergencies twice or more (such as acute exacerbations of a chronic disease) should be well known to the practice already. Certainly, if a further unscheduled event occurs this should trigger entry into the unplanned admission ‘risk register’.
2 Patients with COPD or CHF (or both) who have had at least one unplanned admission within the last year
These conditions are responsible for a high proportion of acute admissions to hospital (8% for COPD, 5% for CHF). Admission is more likely in the context of socio-economic deprivation and where social support is limited. These patients should already be on the QOF register for these conditions.
3 Patients on multiple medications
Polypharmacy is very common nowadays but necessary and appropriate for many.4 There is evidence that those at greatest risk of admission are taking more than ten medications a day. Risks are greater with particularly problematic drugs. For example, NSAIDs, anticoagulants (both warfarin and the new ones), corticosteroids, antidepressants and corticosteroids all increase the risk of admission and this will be greater still if several are taken by the same person.3
It seems sensible to start by reviewing medication use where there are ten or more drugs, with particular vigilance if these problematic drugs are co-prescribed, and looking for people who may be vulnerable to admission, for example where people struggle with their drug regimen or there is cognitive impairment. Pharmacists can be very valuable in supporting this work.
4 People who have three or more co-morbidities
Multimorbidity is as ubiquitous as polypharmacy and may be the driver of it too. It is more common and occurs at an earlier age in deprived populations.5
People who have three or more co-morbidities will be particularly at risk of unplanned admission and will certainly benefit from care planning by a named GP (or nurse) to avoid being treated in the silos of individual specialities.
Highlight key morbidities associated with admission and identify people from the GP computer system (and QOF register) who might have several of these, for example. The combination of three or more of the following can all conspire to provoke unplanned admissions:
· atrial fibrillation
· coronary heart disease
· stroke or transient ischaemic attack
· significant mental health problems
5 Patients who request frequent home visits
Patients in this set may also be more vulnerable to unplanned admission and some of these admissions may be unnecessary. It may be the patients are particularly old or frail, or that their social support systems are not great and the simplest thing is to call for an ambulance when things go wrong. A recent study pointed out that in Scottish hospitals one in ten patients die during their hospital stay and a third die within a year of admission but that hospitals are not ‘geared up’ for care of the dying.6
Frequent home visits may be a sign that planning for end of life care needs consideration and where appropriate can help to avoid death in the unfamiliar setting of a hospital intended for acute intervention. Greater recognition of those people in need of end of life care and enhancing their support may be a particular benefit to come out of the new Unplanned Admissions DES.
Dr Martin Duerden is a part-time GP and deputy medical director for Betsi Cadwaladr University Health Board in north Wales, and a senior clinical lecturer at Bangor University.
1 Pulse. Analysis: Will the unplanned admissions DES work? 3 January 2014. www.pulsetoday.co.uk/your-practice/practice-topics/practice-income/analysis-will-the-unplanned-admissions-des-work/20005442.article#.UzKzDFdXvPo
2 Information Services Division (IDS) Scotland. Scottish Patients at Risk of Readmission and Admission (SPARRA). www.isdscotland.org/Health-Topics/Health-and-Social-Community-Care/SPARRA
3 Hippisley-Cox, J, Coupland, C. Predicting risk of emergency admission to hospital using primary care data: derivation and validation of QAdmissions score. BMJ Open 2013;3:e003482. www.qadmissions.org
4 Duerden M, Avery A, and Payne R. Medicines management of polypharmacy. King’s Fund Report, November 2013. www.kingsfund.org.uk/publications/polypharmacy-and-medicines-optimisation
5 Barnett K, Mercer SW, Norbury M et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet 2012; 380: 37-43.
6 Clark D, Armstrong M, Allan A, et al. Imminence of death among hospital inpatients: Prevalent cohort study. Palliat Med 2014: doi:10.1177/0269216314526443.