1. Interventions: what does the
evidence look like?
Sarah Purdy
Nuffield Trust, Predictive Risk 2013
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. 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. 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. Medication reviews in the community don’t seem
to help in older patients (Thomas et al)
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. 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. 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. 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. 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. Structured discharge from hospital prevents
readmission
• Structured discharge planning tailored to the individual
patient results in fewer readmissions
(Shepperd 2009)
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. 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. Heart failure patients do benefit from intensive
patient focused ‘transition’ case management
on discharge (Huntley, Family Practice 2013)
15. Rehab for COPD works to reduce readmissions
(Puhan, Cochrane 2011)
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. 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. 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. 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. 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. 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
