Interventions: what does the

evidence look like?

Sarah Purdy Nuffield Trust, Predictive Risk 2013

Interventions to reduce avoidable admission

Primary care

Practice features

Medication

review

Case

management

Telemedicine

Hospital at home

Virtual wards

ED department

Assessment/

observation

wards

GPs in AE

Senior clinician

review

Hospital

Structured

discharge

Medication

review

Specialist

clinics

Transition

Transition case

management

Rehabilitation

Self-

management &

education

Co-ordination of

EOL care

General practice: features associated with

fewer admissions

• High continuity of care with a family

doctor is associated with lower risk of

admission in all age groups

• Availability of physician of choice

associated with lower admission

• More GPs per head population linked

with lower admissions in some conditions

• Practices with GP trainers

Some disappointing information….

• Higher ‘quality of care’ measured at practice level including QOF

may or may not be associated with lower rates of admission

Giuffrida 1999, Griffin 2006, Bottle 2007, Purdy 2011 no association

BUT Dusheiko 2011

• Larger practices may have lower

rates of admission for some

conditions e.g. asthma but NOT

all (Saxena 2006, Griffiths 1997,

Yeung 2005, Purdy 2011)

Medication reviews in the community don’t seem

to help in older patients (Thomas et al)

Does case management prevent admissions

in older /elderly people? (Huntley, Family Practice 2013)

Case management initiated in hospital or

on discharge versus usual care in the older

population: relative rate of readmissions

No......but intensive case management

works in mental health

‘Compared to standard care ICM was

shown to reduce hospitalisation and

increase retention in care’

ICM emphasises the importance of small

caseload (less than 20) and high intensity input.

Dieterich, Cochrane 2010

Telemedicine – expensive ? effective Overall evidence is mixed & mainly US

May reduce admissions for heart failure, respiratory conditions, diabetes and HT and elderly with LTC. (automated vital signs monitoring, telephone follow up by nurses (McLean, BMJ 2011)

Recent UK evidence

Whole System Demonstrator cluster randomised trial showed no difference in emergency admissions when the analysis adjusted for differences in baseline characteristics (Steventon, BMJ 2012)

Does intermediate care work?

• “For selected patients, avoiding admission through

provision of hospital care at home yielded similar

outcomes to inpatient care, at a similar or lower cost”

(Shepperd 2009 & 2011)

• “The impact on health service costs of intermediate

care’s role in ...avoiding future hospital admissions,

particularly in frail elderly people is not known.”

(Pearson, SDO 2013)

• Evaluation of virtual wards... (Nuffield Trust)

Interventions in the Emergency

Department

• All types of assessment/observation wards seem to reduce the

number of general ward admissions but benefit to patient unclear

(Cooke 2005)

• GPs in A&E may result in fewer referrals for admission. Cost

benefits may exist but the evidence is weak. (Primary Care

Foundation 2010)

• Senior clinician review reduced inpatient admissions by 11.9%

and specifically reduced admissions to the acute medical

assessment unit by 21.2%. (White 2010)

Structured discharge from hospital prevents

readmission

• Structured discharge planning tailored to the individual

patient results in fewer readmissions (Shepperd 2009)

Pharmacist reviews in hospital don’t reduce

readmissions in general older patients (Thomas et

al)

BUT in older people with heart failure

pharmacist review with follow up reduces

admission RR 0.75 (0.59, 0.95)

Specialist clinics for heart failure reduce

admissions after 12 months (Thomas, Heart 2013)

Study or Subgroup

Atienza 2004

Blue 2001

Bruggink 2007

Capomolla 2002

Doughty 2002

Total (95% CI)

Total events

Heterogeneity: Chi² = 7.94, df = 4 (P = 0.09); I² = 50%

Test for overall effect: Z = 6.06 (P < 0.00001)

Events

39

12

11

9

21

92

Total

164

84

118

112

100

578

Events

79

26

22

37

23

187

Total

174

81

122

122

96

595

Weight

41.7%

14.4%

11.8%

19.3%

12.8%

100.0%

M-H, Fixed, 95% CI

0.52 [0.38, 0.72]

0.45 [0.24, 0.82]

0.52 [0.26, 1.02]

0.26 [0.13, 0.52]

0.88 [0.52, 1.48]

0.51 [0.41, 0.63]

Intervention Usual care Risk Ratio Risk Ratio

M-H, Fixed, 95% CI

0.01 0.1 1 10 100Favours intervention Favours usual care

Absolute risk reduction = 16 per 100 people NNT = 6

]

1

The most effective specialist

clinics for heart failure start off

very intensive and then

reduce over time

BUT no evidence of benefit from specialist clinics in asthma or older/elderly

Heart failure patients do benefit from intensive

patient focused ‘transition’ case management

on discharge (Huntley, Family Practice 2013)

Rehab for COPD works to reduce readmissions (Puhan, Cochrane 2011)

Self-management with education works for

COPD (Effing, Cochrane 2009)

Early palliative care could reduce admissions

and deaths in hospital

• “We examined the effect of introducing palliative care early after diagnosis

on patient-reported outcomes and end-of-life care among ambulatory

patients with newly diagnosed disease.”

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with

metastatic non–small-cell lung cancer. N Engl J Med 2010;363:733-42.

Hospitalisation Standard care

Early palliative

care

Any admission 76.8% 73.5%

Admission within

30 days of death

53.6% 36.7%

Median inpatient

days

7.0 5.0

Coordination of EOL care reduces admissions Marie Curie Delivering Choice Programme

Users were:

• 67% less likely to die in hospital

• 51% less likely to have an emergency hospital admission

in last month and 78% less likely in last 7 days

• 59% less likely to have A&E attendance in last month

and 78% less likely in the last week

• Care coordination centre appeared to be most effective

component

(Wye and Purdy, Marie Curie 2012)

What about integration of care?

• Recent evaluation of 16 integrated care pilots in UK

(mainly horizontal integration of health and social care)

found:

“The summary results of our work showed that although

in general the integrated care sites had lower than

expected outpatient and elective care, there was no

evidence that these sites were reducing the level of

emergency hospital care..no evidence of the anticipated

reduction in emergency admissions”

(Rand 2012)

Summary of evidenced based interventions that

reduce generic admissions

Features of primary care

Continuity of care

Ratio of practitioners to

Patients

GP training

Service interventions

Early senior review in

A & E

Structured discharge from

hospital

Advanced planning

& co-ordination of EOL

Assertive case management

(mental health)

‘The interventions that

have evidence

supporting them are

those that reflect more

traditional qualities of

care such as patient

education, continuity and

coordination of care’

• Continuity of

care with a

GP

• Early senior

review in

A&E

• Advanced

care

planning at

EOL

• Coordination

of EOL care

• Structured

discharge

planning

Some good evidence on interventions that

reduce respiratory and cardiac admissions

• Self-management

/education in COPD and

adults with asthma

• Telemonitoring?

• Pulmonary rehab in

COPD

• Specialist clinics for heart

failure

• BUT case management

uncertain – not all studies

are positive

• Exercise based cardiac

rehab in short term

Further information

• Avoiding hospital admissions: What does the research

evidence say? The King’s Fund 2010

http://www.kingsfund.org.uk/publications/avoiding_hospital.html

• Systematic review of interventions to reduce unplanned

hospital admission NIHR RfPB PB-PG-1208-18013

www.bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmis

sions.pdf.

• HSRN Research Digest - Reducing emergency

admissions: what works?

http://www.hsrlive.org/profiles/blogs/hsrn-research-digest-reducing-

emergency-admissions-what-works