The variability and performance of NHS England’s “Reason to Reside” criteria in predicting hospital discharge in acute hospitals in England. An observational study
Authors: Sapey Elizabeth , Gallier Suzy , Evison Felicity , Hodson James , McNulty David , Reeves Katherine , Ball Simon 
Published: April 2022

Objectives

NHS England (NHSE) advocates using “reason to reside” (R2R) criteria to generate a binary outcome, which supports discharge related clinical decision making. The proportion of patients without R2R and their rate of discharge are reported daily, by acute hospitals in England. R2R is however, not based upon an inter-operable standardised data model (SDM), nor has its performance been validated against its purpose. We aimed to understand the degree of inter- and intra-centre variation in R2R related metrics reported to NHSE, define a SDM implemented within a single centre Electronic Health Record to generate an eR2R, and evaluate its performance in predicting subsequent discharge.

Design

Retrospective observational cohort study using routinely collected health data.

Setting

122 NHS Trusts in England for national reporting and an adult acute hospital in England for local reporting.

Participants

6,602,706 patient-days were analysed using 3 months national data and 1,039,592 patient-days, using 3 years single centre data.

Main outcome measures

Variability in R2R related metrics reported to NHSE. Performance of eR2R in predicting discharge within 24 hours.

Results

There were high levels of intra and inter-centre variability in R2R related metrics (p<0.0001), but not in eR2R. Informedness of eR2R for discharge within 24 hours was low (J-statistic 0.09 – 0.12 across three consecutive years). In those remaining in hospital without eR2R, 61.2% met eR2R criteria on subsequent days (76% within 24 hours), most commonly due to increased NEWS2 (21.9%) or intravenous therapy administration (32.8%).

Conclusions

R2R related performance metrics are highly variable between and within acute Trusts in England. Although case-mix or community care provision may account for some variability, the absence of a SDM is a major barrier to meaningful interpretation of these metrics. The performance of eR2R based on two alternative SDM’s was poor, such that they could not meaningfully contribute to clinical decision making or evaluation of performance.

What is known

There is considerable pressure on hospital bed capacity and significant variation in hospital discharges with concerns raised about delays in discharge planning across National Health Service Trusts. To address this, the UK Government developed a policy and criteria to identify in-patients in whom discharge home, or to a less acute setting, should be considered. The criteria, called “reasons to reside” (R2R) have been promoted as a tool to improve discharge planning and are a mandated metric for central reporting. The performance of R2R has not been assessed.

What this study adds

This study suggests a low performance of the R2R criteria as a clinical tool to identify patients suitable for discharge, and questions its usefulness as a reported metric in its current form. There is significant intra and inter-centre variability in both the reported proportion of patients not meeting R2R criteria, and the proportion of patients not meeting R2R criteria who were later discharged. The proportion of patients not meeting R2R criteria correlates poorly with their rate of discharge over the subsequent 24 hours and the performance of the R2R criteria as dichotomous test to identify patients suitable for discharge is low. Further, the R2R criteria are not a stable phenomenon, with more than half of those who remain in hospital without R2R, subsequently acquiring a R2R during the admission.