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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
...
General practice: features associated with
fewer admissions
• High continuity of care with a family
doctor is associated w...
Some disappointing information….
• Higher ‘quality of care’ measured at practice level including QOF
may or may not be ass...
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 initiate...
No......but intensive case management
works in mental health
‘Compared to standard care ICM was
shown to reduce hospitalis...
Telemedicine – expensive ? effective
Overall evidence is mixed & mainly US
May reduce admissions for heart failure, respir...
Does intermediate care work?
• “For selected patients, avoiding admission through
provision of hospital care at home yield...
Interventions in the Emergency
Department
• All types of assessment/observation wards seem to reduce the
number of general...
Structured discharge from hospital prevents
readmission
• Structured discharge planning tailored to the individual
patient...
Pharmacist reviews in hospital don’t reduce
readmissions in general older patients (Thomas et
al)
BUT in older people with...
Specialist clinics for heart failure reduce
admissions after 12 months (Thomas, Heart 2013)
Study or Subgroup
Atienza 2004...
Heart failure patients do benefit from intensive
patient focused ‘transition’ case management
on discharge (Huntley, Famil...
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 c...
Coordination of EOL care reduces admissions
Marie Curie Delivering Choice Programme
Users were:
• 67% less likely to die i...
What about integration of care?
• Recent evaluation of 16 integrated care pilots in UK
(mainly horizontal integration of h...
Summary of evidenced based interventions that
reduce generic admissions
Features of primary care
Continuity of care
Ratio ...
Some good evidence on interventions that
reduce respiratory and cardiac admissions
• Self-management
/education in COPD an...
Further information
• Avoiding hospital admissions: What does the research
evidence say? The King’s Fund 2010
http://www.k...
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Sarah Purdy: What does evidence look like?

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Transcript of "Sarah Purdy: What does evidence look like?"

  1. 1. Interventions: what does the evidence look like? Sarah Purdy Nuffield Trust, Predictive Risk 2013
  2. 2. 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
  3. 3. 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
  4. 4. 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)
  5. 5. Medication reviews in the community don’t seem to help in older patients (Thomas et al)
  6. 6. 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
  7. 7. 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
  8. 8. 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)
  9. 9. 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)
  10. 10. 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)
  11. 11. Structured discharge from hospital prevents readmission • Structured discharge planning tailored to the individual patient results in fewer readmissions (Shepperd 2009)
  12. 12. 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)
  13. 13. 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 10 100 Favours 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
  14. 14. Heart failure patients do benefit from intensive patient focused ‘transition’ case management on discharge (Huntley, Family Practice 2013)
  15. 15. Rehab for COPD works to reduce readmissions (Puhan, Cochrane 2011)
  16. 16. Self-management with education works for COPD (Effing, Cochrane 2009)
  17. 17. 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
  18. 18. 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)
  19. 19. 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)
  20. 20. 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’
  21. 21. 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
  22. 22. 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
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