1. Analysis of Trends in
Emergency Admissions in
England 2004‐2009
E l d 2004 2009
Ian Blunt
Ian Blunt
Senior Research Analyst
www.nuffieldtrust.org.uk

2. Why emergency admissions?
Emergency hospital admission is:
• Undesirable
• Expensive
• Recorded in routine data
Recorded in routine data
and
• Thought to be increasing in number
Thought to be increasing in number

3. Are emergency admissions rising?
6000
Possible
P ibl reasons
ns (000s)
5000 Aging population
mergency admission
4000 Public expectations
3000 More treatable illness
2000 Defensive medicine
1000 Central targets / payment by
Em
results
lt
0
Changes in other linked services
/97
/99
/01
/03
/05
/07
/09
1996/
1998/
2000/
2002/
2004/
2006/
2008/
Over reliance on A&E for urgent
care

4. Is it just emergency admissions?
100
All outpatients
All i
attendances
Total A&E attendances
Events (millions)
10
Elective inpatient
admissions
Emergency admissions
1
(estimated) Total GP
(estimated) Total GP
consultations
0.1 Calls to ambulance
services
1994/95
5
1995/96
6
1996/97
7
1997/98
8
1998/99
9
1999/00
0
2000/01
1
2001/02
2
2002/03
3
2003/04
4
2004/05
5
2005/06
6
2006/07
7
2007/08
8
2008/09
9
England population

5. Our analysis
The aims of the research were to:
• Unpick the rise in admissions
Unpick the rise in admissions
• Highlight characteristics of excess admissions
• Explore variation at hospital and area level
Explore variation at hospital and area level
This work used the Hospital Episodes Statistics
This work used the Hospital Episodes Statistics
(HES) dataset to examine monthly emergency
admissions over a five year period from April
admissions over a five year period from April
2004 to March 2009.

6. Is the increase due to more readmissions?
Total Year on Increase Number Increase Average
emergency
emergency year
year against
against of
of against
against admissions
admissions
admissions increase 2004/05 individuals 2004/05 per person
/
2004/05 4,441,224
, , ‐ ‐ 3,229,434
, , ‐ 1.38
2005/06 4,666,347 5.1% 5.1% 3,362,317 4.1% 1.39
2006/07 4,707,975 0.9% 6.0% 3,374,751 4.5% 1.40
2007/08 4,771,541 1.4% 7.4% 3,407,204 5.5% 1.40
2008/09 4,964,344 4.0% 11.8% 3,515,537 8.9% 1.41

7. Speaking of readmissions...
6 20%
5
15%
gency readmissions
s
4
ents (millions)
3 10%
Eve
% emerg
2
5%
1
0 0%
Number of readmissions Number of discharges to 31/03 %
Data from NCHOD Compendium

8. How does the rise consume resources?
2.5
25
Estimated cost of the rise
2.4 in emergency admissions
ons)
2.3 is equivalent to at least an
d days (millio
2.2 additional £330 million in
dd l ll
2008/09
2.1
2 (compared to 2004/05
(compared to 2004/05
Emergency bed
1.9 activity costed at 2008/09
1.8 payment levels)
1.7
Not clipped However, the actual value
1.6 is likely to be higher due
Clipped 3 months
1.5 to inflation in the tariff
over time and payment
200404
200408
200412
200504
200508
200512
200604
200608
200612
200704
200708
200712
200804
200808
200812
for non‐tariff work.

9. Is the pattern of stay length changing?
140
Jan 04: 4‐hour A&E April 04:Start of our study window
p y
sions in EBD
target in force
120
100
ency admiss
gory (000s)
80 EBDs:00
EBDs:01
er of emerge
60 EBDs:02
categ
EBDs:03‐05
40 EDBs:06‐10
Numbe
EDBs:11+
EDB 11
20
Small scale PbR in PbR for PbR extended to non‐elective care,
foundation trusts elective outpatients and A&E
care only
0
Apr 2001
Aug 2001
Dec 2001
Apr 2002
Aug 2002
Dec 2002
Apr 2003
Aug 2003
Dec 2003
Apr 2004
Aug 2004
Dec 2004
Apr 2005
Aug 2005
Dec 2005
Apr 2006
Aug 2006
Dec 2006
Apr 2007
Aug 2007
Dec 2007
Apr 2008
Aug 2008
Dec 2008

10. Is the increase related to age?

11. Has the case mix of emergency admission
changed?

12. Is the increase linked to more A&E visits?
6000
s (000s)
5000
attendances
4000
Attendance at major
(type 1) A&E
3000 Admission via major
dmissions / a
(type 1) A&E
2000 Attendance at all A&E
(types 1,2&3)
Ad
1000 All admissions via A&E
All d i i i A&E
0

13. Has the case fatality rate changed?
30000 15%
13%
25000
11%
20000
9%
Deaths
15000 7%
5%
10000
3%
5000
1%
0 ‐1%
Observed Expected Percentage of emergency admissions that end with death
Emergency admissions that end in death, showing observed deaths, expected deaths (standardised for age,
sex, and HRG at 2004/05 rates) and percentage of total emergency admissions

14. Do all trusts exhibit the same pattern?
160% 80%
of short stay emergency admissions
70%
120%
60%
ge
n‐year chang
80%
50%
40% 40%
Year‐on
30%
0%
20%
‐40% 10%
Proportion o
‐80% 0%
2005/06 2006/07 2007/08 2008/09 P
Median, middle 80% range and min/max of 150 stable acute trusts for year‐on‐year change (left) and
percentage of short stay emergency admissions (right)

15. Is the rise linked to the A&E target?
600000 100%
e 4 hours
500000
95%
Breachs/Admissions
400000
% patients seen inside
90%
300000
85%
200000
80%
100000
0 75%
Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in England (all
A&E types)

16. Is the rise linked to the A&E target?
Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in a “normal”
trust (all A&E types)

17. Is the rise linked to the A&E target?
Trade‐off analysis between four‐hour target breaches and short stay emergency admissions in another trust
(all A&E types)

18. Do foundation trusts show the same rise?
100% 3.5
ns (millions)
90%
3
and total
80%
70% 2.5
tage of Engla
cy admission
60% 2
50%
40% 1.5
Percent
30%
Emergenc
1
20%
0.5
10%
0% 0
2004/05 2005/06 2006/07 2007/08 2008/09
% total emergency admissions recieved by FTs in each year
% total trusts that are FTs in each year
Emergency admissions in trusts achieving FT status by March 2009
Emergency admissions in non‐foundation trust

19. Do all PCTs show the same pattern?
Age and sex standardised emergency admission ratio 2004/05 Change in age and sex standardised emergency admission ratio 2004/05 to 2008/09
•Strong correlation with deprivation •No correlation with deprivation or migration
•No correlation with baseline SAR

20. The evidence in summary...
Possible reason Comments
Aging population Accounts for some of the increase, but not all
Public expectations Increased demand for health services
Increased demand for health services
More treatable illness No significant change in case mix, although vague
symptoms increase disproportionately
y p p p y
Defensive medicine The increase is due to short stay admissions; but could
be many other explanations for these...
Central targets / payment
targets / payment No evidence of 4 hour target driving systematic
No evidence of 4 hour target driving systematic
by results increase, and slightly pre‐dates PbR
Change in other linked Could regional variation in the increase be a symptom
services
i of this?
f thi ?
Over reliance on A&E for A&E attendance is increasing, as are admissions
urgent care through A&E

21. Efficiency breeds inefficiency paradox?
Reduction in More beds
length of stay available
Provider efficiency System inefficiency
Less severe Admission
cases admitted threshold reduced
Better and more Lower acuity cases
efficient care
efficient care using costly
using costly
inpatient care

22. How might the paradox be addressed?
Three main areas that policy‐makers and commissioners of care
Three main areas that policy makers and commissioners of care
should focus on:
• C ti
Continue to scrutinise and reform the system for reimbursing hospitals for
t ti i d f th t f i b i h it l f
care
• Ensure that shorter stays for admitted patients which free up beds available
Ensure that shorter stays for admitted patients ‐ which free up beds available
for care ‐ are translated into reducing the number of hospital beds, rather than
lowering the threshold for hospital admission
•Link hospital care more with out‐of‐hospital care providers (primary and
community services) and give both incentives to keep people well so that
admission is avoided, and disincentives to admit patients to hospital unless
absolutely necessary