Trends in Emergency Admissions in England 2004-2009 July 2010 © Nuffield Trust Why emergency admissions? Emergency hospital admission is: • Undesirable • Expensive • Recorded in routine data and • Thought to be increasing in number © Nuffield Trust Are emergency admissions rising? Possible reasons •Aging population •Public expectations •More treatable illness •Defensive medicine •Central targets/ Payment by Results •Changes in other linked services Number of emergency admissions in England 1996-2009, with period investigated marked in red Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? •Over reliance on A&E for urgent care Is it just emergency admissions? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Our analysis The aims of the research were to: • Unpick the rise in admissions • Highlight characteristics of excess admissions • Explore variation at hospital and area level This work used the Hospital Episodes Statistics (HES) dataset to examine monthly emergency admissions over a five year period from April 2004 to March 2009. © Nuffield Trust Is the increase due to more readmissions? How does the rise consume resources? Estimated cost of the rise in emergency admissions is equivalent to at least an additional £330 million in 2008/09 (compared to 2004/05 activity costed at 2008/09 payment levels). 2.5 2.4 2.2 2.1 2 1.9 1.8 1.7 1.6 Not clipped Clipped 3 months 1.5 200404 200406 200408 200410 200412 200502 200504 200506 200508 200510 200512 200602 200604 200606 200608 200610 200612 200702 200704 200706 200708 200710 200712 200802 200804 200806 200808 200810 200812 200902 Emergency bed days (millions) 2.3 However, the actual value is likely to be higher due to inflation in the tariff over time and payment for nontariff work. Is the pattern of stay length changing? Number of emergency admissions categorised by emergency bed days (EBDs) used in spell, excluding spells in mental health and undefined Healthcare Resource Groups (HRGs) 2001-2009 Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? Is the increase related to age? Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Has the case mix of emergency admissions changed? Has the case fatality rate changed? 30000 15% 13% 25000 11% Deaths 20000 9% 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 Is the rise linked to the A&E target in England? Trade-off analysis between four-hour target breaches and short stay emergency admissions in England (all A&E types) Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? Is the rise linked to the A&E target in particular trusts? Trade-off analysis between four-hour target breaches and short stay emergency admissions in another trust (all A&E types) Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency Do all PCTs show the same pattern? (a) Age and sex standardised emergency admission ratio in 2004/05 (green, lowest, to red, highest) (b) Absolute increase by 2008/09 (blue, dark = highest, light = lowest) Reproduced from Trends in emergency admissions in England 2004-2009: is greater efficiency breeding inefficiency? 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 More treatable illness No significant change in case mix, although vague symptoms increase disproportionately Defensive medicine The increase is due to short stay admissions; but could be many other explanations for these... Central targets/Payment by Results No evidence of 4-hour target driving systematic increase, and slightly pre-dates PbR Change in other linked services Could regional variation in the increase be a symptom of this? Over reliance on A&E for urgent care A&E attendance is increasing, as are admissions through A&E Efficiency breeds inefficiency paradox? Reduction in length of stay Provider efficiency Less severe cases admitted Better and more efficient care More beds available System inefficiency Admission threshold reduced Lower acuity cases using costly inpatient care www.nuffieldtrust.org.uk Sign-up for our newsletter www.nuffieldtrust.org.uk/newsletter Follow us on Twitter (http://twitter.com/NuffieldTrust) July 2010 © Nuffield Trust