Title: Identification of emergency and urgent care system characteristics affecting preventable unplanned admission rates
Funder: Department of Health (England)

Abstract: Conceptual framework:The conceptual framework for the study is that patients health professionals and health services operate within a health and social care system. Although it is important to consider the role of individual services such as primary care and emergency departments in the prevention and avoidance of emergency admissions each service operates within a wider local system including GP out of hours walk-in centres NHS Direct same day GP urgent care and 999 ambulance. Attention is needed to the system factors affecting variation in avoidable emergency hospital admissions. Variation may be explained by system factors as well as population factors such as age and sex. System factors include the structure of the system (service configuration temporal and geographical access) the performance of individual services within the system (e.g. a change in access to urgent daytime GP services can impact on other services in the system) patient understanding of the system (if patients are not aware of all available services they may wait until crisis point or attend familiar services such as emergency departments) and coordination between services and between departments in services in the system (e.g. co-location of services single point of access informational continuity).Research aim:To identify system factors explaining variation in avoidable emergency admissions in different emergency and urgent care systemsResearch methods:Two definitions of a system are used - primary care trust resident populations and acute trusts catchment area populations.1. Calculate the performance indicator standardised avoidable emergency admission rate for each emergency and urgent care system in England using a combination of Hospital Episode Statistics (HES) and Office of National Statistics (ONS) data for 2006/7-8/9. That is produce directly standardised admission rates for 14 conditions where admission could be avoided by a good urgent care system. We will standardise for age sex and clinical condition.2. Explore the relationship between this indicator rates of unplanned admissions and the Nuffield Trust indirectly standardised admission ratio.3. Test the extent to which population health and system factors explain variation in the standardised avoidable emergency admission rate. These factors will be obtained from routine sources and will include supply factors (e.g. number of emergency beds per 1000 number of GPs per 1000 taking vacancies into account variety of emergency and urgent care services available) and system geographic dispersion using a rurality index.4. Identify systems with high and low rates which cannot be explained by population health and system factors in 3.5. Undertake six case studies of systems - 3 with high unexplained rates and 3 with low unexplained rates - to identify more complex system factors affecting variation. Apply Yins multiple case study approach to describe system configuration and integration using documentary analysis; system use using local routine data; and semi-structured face-to-face interviews with stakeholders to identify perceptions of key issues affecting avoidable emergency admissions and increases in these admissions. Stakeholders include commissioners emergency department staff (consultant junior doctor lead nurse manager) ward/bed manager GPs GP out of hours service GPs with a special interests in nursing homes 999 emergency ambulance social care primary care emergency and urgent care network board lead if available managers of urgent care services such as single point of access and PALS lead. Approximately 15 interviews will be undertaken per case totalling around 90 interviews. Interviews will cover key drivers of emergency admissions avoidable admissions and increases (socio-demographic services and particularly system) admission thresholds in hospitals problem points in the system coordination between services access to the system strategies used to manage demand and further solutions needed.Timeplan: 27 months in total; calculate indicators 1-3 months; ethics and research governance for case studies 4-10 months; case studies 8-20; analysis and report 21-27 months.Research outputs: A tested performance indicator for avoidable emergency admissions and modifiable system factors to help regulators monitor and reduce avoidable emergency admissions.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE