Ambulatory Care Sensitive Emergency Admissions Analysis report

Kent, Surrey and Sussex Ambulatory Care Sensitive Emergency Admissions Analysis Report April 2014 Authors: Kate Cheema, Quality Observatory Simon Berry, Quality Observatory

Contents

3

List of tables

4

List of figures

4

Foreword

5

Executive summary

6

Introduction

7

Method

8

National summary

10

High level summary in the Kent, Surrey and Sussex region

11

Resource redistribution opportunities

19

Condition focus: pneumonia

20

Condition focus: urinary tract infections and pyelonephritis

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Condition focus: epilepsy and convulsions

28

Glossary of terms

31

References

31

Appendix A

32

Appendix B

34

Foreword

4

List of Tables Table 1:

List of conditions included in analysis

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Table 2:

Estimated reduction in admissions and costs for each of three scenarios

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List of Figures Figure 1:

Indices of Multiple Deprivation by LSOA across KSS region, with CCG boundaries

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Figure 2:

Standardised ACS admission rates per 1,000 by type across KSS, 12 months to November 2013

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Figure 3:

Condition breakdown of numbers of ACS admissions across KSS, 12 months to November 2013

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Figure 4:

Age and gender breakdown of numbers of ACS admissions across KSS, 12 months to November 2013

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Figure 5:

Age, gender and deprivation standardised ACS admission rates per 1,000 for CCGs across KSS, 12 months to November 2013

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Figure 6:

Age and gender standardised ACS admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

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Figure 7:

12 month rolling ACS admission rate per 1,000 across all KSS commissioners

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Figure 8:

12 month rolling ACS admission rate per 1,000 for each category of ACS condition across all KSS commissioners

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Figure 9:

12 month rolling average length of stay (orange line) and proportion of admissions with a zero-day length of stay for all ACS conditions across all KSS commissioners

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Figure 10:

12 month rolling pneumonia admission rate per 1,000 across all KSS commissioners

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Figure 11:

Age and gender standardised pneumonia admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

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Figure 12:

Age and gender breakdown of numbers of pneumonia admissions across KSS, 12 months to November 2013

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Figure 13:

12 month rolling pneumonia admission rate per 1,000 for Guildford & Waverley CCG (yellow) vs KSS region (orange)

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Figure 14:

Age and gender standardised UTI/pyelonephritis admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

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Figure 15:

Age and gender breakdown of numbers of UTI/pyelonephritis admissions across KSS, 12 months to November 2013

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Figure 16:

12 month rolling UTI/pyelonephritis admission rate per 1,000 for Crawley CCG (yellow) vs KSS region (orange) for all age groups

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Figure 17:

12 month rolling UTI/pyelonephritis admission rate per 1,000 for Crawley CCG (yellow) vs KSS region (orange) for 0-18 years age group

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Figure 18:

12 month rolling epilepsy and convulsions admission rate per 1,000 across all KSS commissioners

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Figure 19:

Age and gender breakdown of numbers of epilepsy and convulsions admissions across KSS, 12 months to November 2013

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Figure 20

Age and gender standardised epilepsy and convulsions admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

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Kent, Surrey and Sussex is a region with much to be proud of, not least our good health outcomes and a clear commitment and track record of continuously improving the quality of services for the citizens in our care. Building on our existing strengths, combined with world class evidence and analysis will allow us to adapt to the challenges posed by demographic change, the state of public finances and increasing public expectation.

Last year’s report, from The Health Foundation and Nuffield Trust, ‘Focus on preventable admissions’ gave real insight into emergency hospital admission trends and opportunities. It prompted us to analyse the position here on a theme which is so critical to the long term sustainability of health and social care.

It addresses the wishes of 85% of respondents to last year’s poll who wanted the AHSN to dedicate some time and attention to emergency hospital admissions.

Emergency hospital admissions for ambulatory care sensitive conditions are a key indicator of how much progress commissioners and providers have made towards their strategic intention of moving care closer to home and supporting people, especially those with long term conditions, to live healthy lives.

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I am delighted to have commissioned and published this analysis. The first step towards improvement is to understand what you need to change; this report is a position statement on ambulatory care sensitive admissions for the region and, as with all the best analysis, will prompt you to ask more probing questions and discuss further what action can be taken in your locality. The analysis presented in this report, alongside the associated analytical tool, provides authoritative, detailed information on emergency hospital admissions for ambulatory care sensitive conditions. The report also highlights areas of good practice from which lessons can be learned. I hope to see this spread across the region, shaping strong support and learning networks between peers.

I trust that this report will support the spread of existing best practice, and help commissioners and providers to work better to deliver the transformation of health and care services that is needed to ensure that people living in Kent and Medway, Surrey and Sussex receive consistently high quality care when and where they need it.

Guy Boersma Managing Director Kent Surrey Sussex AHSN

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Executive summary

Ambulatory care sensitive (ACS) hospital admission rates are a commonly used indicator of system health and sustainability.

Identifying the volume of preventable emergency hospital admissions contributes to an understanding of outstanding opportunities to deliver value for money.

Kent, Surrey and Sussex as a region has relatively low rates of ambulatory care sensitive admissions: half of the rate for England as a whole. Nevertheless, in Kent, Surrey and Sussex almost 20%, or one in five, of all emergency hospital admissions are for ambulatory care sensitive conditions, a similar proportion to that as England as a whole. More than half of these admissions are related to just a handful of conditions, some of which disproportionately affect elderly people and others which impact primarily on younger patients; this serves as a reminder that preventable emergency admissions are issues which can affect the whole population.

Whilst rates of ambulatory care sensitive admissions in Kent, Surrey and Sussex are relatively low, the overall rate is increasing rather than decreasing, at a similar rate to that of England which increased by 48% over an eleven year period. Less than half of this increase is explained by population growth and demographic change. Of particular concern is the rapid growth of ‘other and vaccine preventable’ ambulatory care sensitive admission rates as well as the steady rise in acute ambulatory care sensitive conditions. Interestingly, chronic ambulatory care sensitive conditions show limited growth, in stark contrast to the increasing demand in this area from an ageing population that is living longer.

Clear variations between areas are apparent at both a national and regional level. Most areas show increased rates of ambulatory care sensitive admissions over time, but there is variation evident in the degree of change and the extent to which this is evident in different ambulatory care sensitive conditions. Levels of deprivation, which are strongly linked to rates of ACS admission,

Introduction

can explain some of this variation but there are still significant differences between areas even after deprivation is taken into account. The impact of deprivation is lesser in the Kent, Surrey and Sussex region than in England as a whole.

A number of scenarios have been applied to the data in an effort to provide a high level estimate of the scale of resource redistribution opportunity from hospital to out of hospital settings. The high level estimates from these scenarios range from £6.7m to £27.3m. Despite the relatively good rates of ACS admission rates in the region, opportunities remain to redistribute resources from hospital to out of hospital settings.

This report sets out some highlights from analysis of specific ACS conditions.

Pneumonia is a significant driver of growth and disproportionately affects older people.

There is significant variation in emergency hospital admission rates between clinical commissioning group areas and the majority of emergency hospital pneumonia admissions are shown to be primarily for pneumonia and not pneumonia as a co-morbidity. Urinary tract infection and pyelonephritis is the most common ACS admission reason across the Kent, Surrey and Sussex region. Rates have increased by 34% in the past six years. These admissions are not purely the domain of older people but also have an impact on younger females which may have implications for public health. Epilepsy and convulsions is an ACS condition where admissions are evident in all age groups but especially younger children; it is highlighted as an example of where a condition can disproportionately impact a younger group, and highlights the fact that ACS admissions are not just a concern for the older population.

Admission to hospital is often a distressing and difficult time for patients and carers, and particularly so if the admission is unplanned and as a result of a rapid deterioration of health. Perhaps this is further exacerbated when the admission could have been prevented. Emergency hospital admissions that fall into this category, ambulatory care sensitive (ACS) conditions, are seen as largely preventable and are often used as an indicator of health system performance.

Because of this, and the expensive nature of such activity, concerted efforts have been made to reduce ACS admissions in an effort to reduce costs and increase productivity (Purdy, 2010). However, research from the Nuffield Trust (Nuffield Trust, 2013) shows that the rate of these admissions has been steadily increasing over recent decades and accounts for a large proportion of emergency admissions overall, some 15.9% in 2009/10 according to Tian et al (2012).

Kent, Surrey and Sussex boasts a relatively affluent and healthy population but nevertheless is not immune to the impact that high levels of ACS admissions can have

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on individual patients and the sustainability of the health and care system as a whole.

To mitigate this, commissioners and providers have out of hospital care strategies to meet the growing demand and expectation from a growing and ageing population. Deeper understanding of ACS emergency hospital admissions and their growing volumes across the region is therefore critical for every health economy looking to deliver affordable and sustainable care closer to home.

This report describes the position with regarding ACS conditions in Kent, Surrey and Sussex, utilising a similar methodology to that employed by the Nuffield Trust in their 2013 analysis. The report focuses on some specific areas of interest and also estimates the scale of financial resource redistribution opportunity available through reductions in ACS admissions.

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Method

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The methodology used to analyse ACS condition related emergency admissions was based on data from acute providers and commissioners sourced from Secondary Uses Service (SUS) extracts. Data at the national level and that used for direct standardisation was sourced from Hospital Episode Statistics (HES) extracts. As HES data is directly derived from SUS data it is not anticipated that there will be any impact of using SUS as a source for local data and HES for national aggregates information.

ACS emergency admissions were identified through the presence of specific diagnostic codes in the admission episode. As far as possible the same methodology as employed by the Nuffield Trust in their 2013 publication ‘Focus on Preventable Admissions’ (Nuffield Trust, 2013) was utilised, with the majority of conditions identified using primary diagnosis, although a small number also took diagnostic codes in subsequent positions into account.

Table 1: List of conditions included in analysis

The ACS conditions identified are listed in table 1 (please refer to appendix A for a full breakdown of diagnostic codes used). There are three categories of ACS conditions, as described by Billings et al. (1993): • Acute - those conditions that can occur as an isolated episode with the patient often returning to full health, where early intervention can prevent more serious progression • Chronic - long term conditions, where effective care can prevent periods of excerbation • Other and vaccine preventable (O&VP) this includes pneumonia, which is vaccine preventable in some circumstances, and conditions that can generally be prevented through the use of vaccines or other interventions.

Acute conditions

Chronic conditions

OVP conditions

Cellulitis

Angina

Influenza*

Dehydration

Asthma

Pneumonia*

Dental conditions

Chronic obstructive pulmonary Tuberculosis disease

Ear, nose & throat infections

Congestive heart failure

Gangrene*

Convulsions and epilepsy

Nutritional deficiencies

Diabetes complications*

Pelvic inflammatory disease

Hypertension

Perforated/bleeding ulcer

Iron deficiency anaemia

Urinary tract infection /pyelonephritis

*Also included as a subsequent diagnosis

Other vaccine-preventable*

A number of indicators were investigated from both a commissioner (CCG) and provider (acute trust) perspective in order to fully understand the variation between areas and organisations. Population denominators and age and gender profiles for commissioner organisations were derived from the Office for National Statistics midyear population estimates 2012 (ONS, 2013).

Provider population data was sourced from the latest Eastern Region Public Health Observatory acute population estimates for 2011 (ERPHO, 2012). The latter of these provide an estimate of the catchment population covered by an acute trust, based on all admissions, elective admission only and emergency admissions and are calculated using the proportional flow method. Direct standardisation by age and gender was carried out by calculating age and gender specific admission rates and applying them to the European Standard Population.

The indicators examined in the analysis were: • Emergency Admissions - total number of emergency admissions for a selected ACS condition • Emergency Admissions per 1000

population - total number of emergency admissions for a selected ACS condition, divided by the population for the organisation or area selected

• Percentage Emergency Admissions ACS total number of emergency admissions for a selected ACS condition divided by the total emergency admissions for the organisation or area selected • Percentage Emergency Admission Bed Days ACS - total number of bed days for a selected ACS condition divided by the total emergency bed days for the organisation or area selected • Length of Stay - total bed days consumed by a selected ACS condition divided by the total number of emergency admissions for that condition • Percentage Emergency Admissions from care homes - total number of emergency admissions for a selected ACS condition that were admitted from a care home setting divided by the total emergency admissions for the organisation or area selected.

This examination of a number of indicators at an organisational/area level, by individual and grouped ACS conditions gives rise to a very large number of permutations in terms of how the data can be viewed. Therefore, an exploratory analysis tool was developed to allow easy manipulation of variables and the ability to view trends and snapshots at a variety of geographical, organisational and condition levels. The figures throughout this paper have been taken from that tool; images of this tool’s primary user interface can be seen in appendix B and the tool itself is available via the KSS AHSN website (www.kssahsn.net).

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National summary

In their paper ‘Focus on Preventable Emergency Admissions’ (Blunt, 2013), the Health Foundation and Nuffield Trust utilised Hospital Episode Statistics (HES) data to review long term trends at a national level.

There were a number of key findings that summarise the overall picture nationally: • ACS admissions make up one in every five emergency admissions to hospitals and half of these are accounted for by five of the nineteen ACS conditions; UTI/ pyelonephritis, pneumonia, COPD, epilepsy and convulsions and ENT infections • ACS admission increased by 48% in the period 2001 to 2013, with less than half of the increase explained by population growth and demographic change. These increases varied by type of ACS condition, with chronic conditions changing very little but with significant increases in acute conditions

High level summary in the Kent, Surrey and Sussex region

• Most areas showed increased rates of ACS admissions over time, although a small number of areas showed notable reductions relative to the national picture • Of the five main ACS conditions, three disproportionately affect older people (COPD, UTI/pyelonephritis and pneumonia) whilst the remaining two disproportionately affect children and young people (epilepsy and convulsions and ENT infections). This highlights the importance of considering the issue of ACS admissions across all age groups • Levels of deprivation are strongly linked to rates of ACS admission, especially for specific conditions such as COPD. However, there are still significant differences between areas even once deprivation is taken into account.

These key points are often mirrored in the findings for Kent Surrey and Sussex which are explored in more detail below. Other reviews of ACS conditions data carried out by the King’s Fund (e.g. Tian et al., 2012; Purdy, 2010) also highlight similar issues, providing a solid national basis from which to view the more localised Kent Surrey and Sussex analysis presented in the rest of this report.

Figure 1: Indices of Multiple Deprivation by LSOA across KSS region, with CCG boundaries

The Kent, Surrey and Sussex region covers a population of a little over 4.8 million people, with six upper tier local authorities, emergency hospital admission services provided by 12 acute trusts, commissioned by 20 CCGs and overseen by two local area teams of NHS England. Whilst the general health and life expectancy of the region is better than the rest of England, there are clear inequalities, with the health of the population in Thanet, Shepway, Hastings and Brighton worse than in more affluent areas such as Guildford, Waverley and Elmbridge. This is clearly illustrated in figure 1, which indicates the degree of variation in terms of deprivation across the region. Tian (2012) reports a strong correlation between

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deprivation and ACS admission rates reporting a correlation co-efficient of r=0.93 (Tian, 2012) and the Health Foundation/ NuffieldTrust report (Blunt, 2013) stated that “rates of ACS admissions for people living in the most deprived vigintile of LSOAs were 3.15 times higher than those in the least deprived”. However, the relationship between deprivation and age/sex standardised ACS admission rate is less strong in the region than in the country as a whole, with a correlation co-efficient of r=0.58.

With this context in mind, a high level cross-sectional and longitudinal review of ACS emergency admissions across the region highlights some interesting points.

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High level summary in the Kent, Surrey and Sussex region

In a cross sectional analysis, Kent, Surrey and Sussex reported a total of 12.8 ACS admissions per 1,000 population (standardised for age and gender) in the year to November 2013, against an England rate of 25.8. This is also evident in ‘Focus on Preventable Admissions’ (Blunt, 2013) where the majority of areas within Kent, Surrey and Sussex are shown as having a rate well below the England mean for the period 2012/13. The rate of 12.8 per 1,000 is less than half of the overall England rate, which could be regarded as a cause for celebration as ACS admissions, as discussed above, are often used as a proxy measure for overall system health.

However, this assumption that ‘low is good’ is just that; an assumption. An absence of ACS admissions is not necessarily an indicator of better care being delivered elsewhere, just that it is not being delivered

Figure 2: Standardised ACS admission rates per 1,000 by type across KSS, 12 months to November 2013

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It can be seen that the rate per 1,000 population varies between types of ACS condition (see figure 2). This is comparable with the overall national picture, but the relative difference between acute and chronic is smaller in Kent, Surrey and Sussex (a 3.5% difference between the two rates, against a 4.7% difference for England as a whole).

in a hospital context. Additional information from primary and community care would need to be utilised to assess whether or not low ACS admission rates is accompanied by better care outside of hospital, but this is outside the scope of this analysis.

The Kent, Surrey and Sussex rate of ACS conditions is equivalent to 19.4% of the 387,547 emergency admissions across the region in the year to November 2013. This is comparable to the 20% figure found for England (Blunt, 2013). The cost of an ACS condition admission in accounting for the mix of conditions across the region, is approximately £1,288 per admission, with many conditions not having a differential tariff for short length of stay, including some high volume conditions such as epilepsy and convulsions. This is discussed in more detail in the Resource Redistribution section later in this document.

An analysis of ACS admissions by condition raises some interesting points. Figure 3 shows the breakdown of the number of ACS emergency admissions by individual condition. Urinary Tract Infections (UTI)/ pyelonephritis, pneumonia and COPD between them account for over 42% of

Figure 3: Condition breakdown of numbers of ACS admissions across KSS, 12 months to November 2013

the total, with the top seven conditions collectively accounting for over 70%. The breakdown is similar in many respects to the national findings; for example, COPD, pneumonia and UTI/pyelonephritis are all the most common ACS conditions nationally. However, in the conditions with smaller volumes there are some differences; ENT infections were the second highest condition amongst the acute conditions nationally, but fourth highest behind UTI/ pyelonephritis, gastroenteritis and cellulitis in Kent, Surrey and Sussex. Some of these conditions will be looked at in greater detail later in this report.

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High level summary in the Kent, Surrey and Sussex region

The age and gender breakdown for numbers of ACS admissions can be seen in figure 4.

This clearly illustrates that the number of ACS admissions generally increases with age but at a slightly higher rate in males than in females. The considerably higher numbers in females over 85 years of age, compared with males in the same age group is likely to be due to differences in life expectancy

between the genders. Figure 4 also illustrates that ACS emergency admissions is not just an issue in more elderly age groups in Kent, Surrey and Sussex, but shows children under four, and particularly males, as being an age group to be aware of. A slight peak is also evident in females aged 15 to 29 years of age. This pattern across the genders and age groups is comparable to the national picture.

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Figure 5: Age, gender and deprivation standardised ACS admission rates per 1,000 for CCGs across KSS, 12 months to November 2013

Figure 4: Age and gender breakdown of numbers of ACS admissions across KSS, 12 months to November 2013

The highest rate in Medway CCG is greater than that of the lowest in Surrey Downs by a factor of more than three. The variation evident does appear to be related, broadly, to deprivation; areas of greater deprivation in East Sussex, north west Kent and east Kent all exhibit higher ACS admission rates.

By further adjusting the rates to reflect

Finally, in this cross-sectional analysis, a breakdown of age and gender standardised ACS admission rates by CCG highlights the degree of variation across the region.

Figure 5 shows the standardised rates for

ACS emergency admissions for all the CCG commissioners across Kent, Surrey and Sussex against the England mean. All CCGs show rates of admission below the England mean, but there remains significant variation between CCG areas.

Figure 6: Age and gender standardised ACS admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

the difference in deprivation it can be seen that rates overall change only marginally and that varying levels of deprivation are unlikely to explain all of the variation evident; differences in clinical practice and service provision will have an impact on the variability between areas.

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High level summary in the Kent, Surrey and Sussex region

Looking at the data from a longitudinal point of view it can be seen that the overall rate of ACS emergency admissions per 1,000 population is rising, as can be seen in figure 7. Over the time period shown from March 2007 to November 2013 the rate has increased by 15% and the overall pattern has been a reasonably smooth one with some suggestion of a reduction in the rate in the latter part of 2013 onwards.

Over the same time period, the rate of ACS admissions in England increased by

approximately 13%, which is similar to the picture in Kent, Surrey and Sussex.

There is however disparity between the different types of condition and the degree of increase. Figure 8 right presents a triptych showing the rolling 12 month admission rate per 1,000 population from an ‘all commissioner’ viewpoint for each of the 3 categories of ACS emergency admission.

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Figure 8: 12 month rolling ACS admission rate per 1,000 for each category of ACS condition across all KSS commissioners

increase of just 3%. The final category is the fastest growing of the three, but account for far fewer admissions. The OVP category shows an increase from a rate of just 0.23 per 1,000 at the beginning of the time

period shown, to 0.41, an increase of 78%, equivalent to an extra 700 admissions. This increase is driven almost entirely by changes in pneumonia emergency admission rates, which will be discussed in more depth.

These findings in many respects are comparable to England as a whole, where significant growth is seen in acute ACS conditions, greater stability is evident in chronic ACS conditions and a large degree of growth can be seen in OVP ACS conditions, but starting from a much lower baseline number than the other categories.

Population demand for care in chronic conditions is growing significantly but the growth in ACS admissions for these disease areas remains relatively stable. There are variations between conditions with notable decreases in ACS admission rates in angina and asthma across the region, against a background of increasing prevalence (between 2006/07 and 2010/11 an increase of 6% in asthma prevalence was reported,

(Department of Health, 2012)). However, chronic obstructive pulmonary disease (COPD) ACS admissions have risen by 14% from March 2007 to November 2013, so whilst the overall picture for chronic conditions appears positive there are still areas of opportunity.

Figure 7: 12 month rolling ACS admission rate per 1,000 across all KSS commissioners

The first of these charts shows the trend from March 2007 to November 2013 across Kent, Surrey and Sussex for the acute ACS conditions only. These show a steady increase over time from around 1 admission per 1,000 to 1.2 admissions per 1,000, an increase of 20% and equivalent to an extra 860 admissions. This picture is very different from that shown for chronic conditions, where there is much more variation over time but significantly less

growth; as this data is shown as a rolling 12 month rate, seasonality should not play a part, and yet the cyclical nature of the pattern for these chronic ACS emergency admissions is suggestive of some kind of systematic and regular change which may require further investigation. In general, however, only a slight increase in the chronic ACS condition category is evident, moving from 1.2 to 1.24 admissions per 1,000 over the time period shown, an

The England data does not mirror the fluctuating pattern in the chronic ACS conditions which is evident for Kent, Surrey and Sussex. This appears driven by congestive heart failure, epilepsy and convulsions and COPD ACS admissions.

The pattern that is evident locally warrants further investigation and analysis, including data quality issues, to identify the potential reasons for these cyclical changes.

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Figure 9: 12 month rolling average length of stay (orange line) and proportion of admissions with a zero-day length of stay for all ACS conditions across all KSS commissioners

High level summary in the Kent, Surrey and Sussex region

Resource redistribution opportunities

Length of stay can be an important indicator in understanding the complexity of cases admitted and the degree to which they may or may not be inappropriate admissions. For example, a high average length of stay for a particular condition may indicate cases which require long term hospitalisation and are thus likely to be appropriate. A high proportion of admissions where the length of stay is very short, less than one day for example, could be indicative of a number of admissions less appropriate for hospitalisation which could have been treated more effectively and efficiently in community settings. Assessing the length of stay for ACS admissions across the region shows a stable average stay of between 6.5 and 7 days as illustrated by the orange line in figure 9. This figure rises to 8 days if admissions with a zero-day length of stay are removed from the calculation. In conjunction with this, the grey line shows the proportion of ACS admissions with a zero-day length of stay (read from the right hand side axis of the chart). This is around 20% of admissions with the long term trend indicating a slow but steady decline in this proportion by approximately 13% between November

As has been noted above, emergency hospital admissions for the ACS conditions are generally viewed as avoidable and have frequently been cited as presenting a value for money improvement opportunity.

2008 and November 2013. This 20% of ACS admissions equates to 15,100 having a zero-day length of stay in the year to November 2013.

Another area of specific interest is the proportion of ACS admissions that are admitted from the care home sector.

Anecdotal evidence suggests that this area may be a candidate for targeted interventions to reduce such admissions.

However, the data suggests only 0.3% of all ACS admissions were from a care home.

This low number is likely to reflect the relatively poor completion of key data items used to derive this indicator which make in depth analysis difficult to carry out without local understanding of the care home sector.

This has been carried out successfully by a number of CCGs including Surrey Heath CCG and there may be opportunity to share the methodology and findings more widely where care home admissions are an area of particular interest. Therefore, whilst the indicators remain available for review in the exploratory analysis tool associated with this report, it is not explored further in this report.

Table 2: Estimated reduction in admissions and associated financial sum for each of three scenarios

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The average cost per ACS admission in the region has been calculated at £1,288, using a breakdown of the casemix, length of stay and complication rates of the ACS admissions but does not account for local pricing, market forces factors applicable to individual areas or block contract arrangements. Therefore, the potential financial resource redistribution opportunities presented here are estimates only. As noted above, a number of ACS conditions are not subject to a differential tariff for short stay admissions and as such present a particular opportunity for resource redistribution by commissioners. High volume ACS conditions which do not have a short stay tariff are: • Asthma • Angina • ENT infections • Epilepsy and convulsions

In this section the estimated resource redistribution opportunities for the region are explored in more depth. A three pronged approach is undertaken to assess the scale of opportunity based on a variety of improvement scenarios: • Having the lowest rate in KSS (scenario 1): all CCGs reduce their ACS admission rates to the KSS upper quartile rate; those already lower than this rate will sustain it • Moving along the quartiles in KSS (scenario 2): all CCGs reduce their ACS admission rates to the next quartile rate, for example those in the third quartile will move to the upper quartile, those in the second quartile will move to the third quartile and so on; those already in the upper quartile will move to the lowest CCG admission rate in KSS • Having the lowest rate in England (scenario 3): all KSS CCGs reduce their ACS admission rates to the lowest rate in England based on Tian (2012); as KSS is already in general lower than the rest of England in terms of overall rates this is an ambitious but potentially attainable scenario.

As an example, ENT infections has a zero-day length of stay rate of over 53%, which means that the majority of these admissions are paid at full tariff (of more than £450) without having an overnight stay in hospital.

Table 2 below outlines the estimated reductions in admissions and the estimated level of financial resources released for reinvestment for a 12 month period for each of the scenarios outlined above.

Scenario

Estimated number of admissions reduced

Estimated resource redistribution level

Having the lowest rate in KSS

11,515

£14.8m

Moving along the quartiles in KSS

5,196

£6.7m

Having the lowest rate in England

21,160

£27.3m

Resources released for reinvestment would need to cover the additional costs involved in treating patients elsewhere, for example in a community or primary care settings.

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Condition focus: pneumonia

Pneumonia has the second highest volume of ACS admissions and is the primary driver behind the growth in the OVP category. This section reviews the detail of pneumonia admissions and the variation between commissioners and providers across Kent, Surrey and Sussex.

Across the region, pneumonia is the condition which shows the highest growth in admissions, where pneumonia is identified in any diagnostic position in the admitting episode, with approximately 84% growth in rolling 12 month admission rate per 1,000 between March 2007 and November 2013 (see figure 10) with growth really starting from September 2008. At the beginning of this time period these admissions accounted for 1.6% of all emergency admissions and

by November 2013 this had risen to 2.8%.

Figure 10: 12 month rolling pneumonia admission rate per 1,000 across all KSS commissioners

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This programme began after the start of the time period reviewed here but is indicative of the kinds of issues that may impact on pneumonia admissions beyond changes in demographics or disease prevalence.

Against this background, average length of stay has remained reasonably static, between 11 and 12 days.

Equally, the proportion of pneumonia admissions that show a zero-day length of stay has also remained fairly stable, with between 5% and 6% of pneumonia admissions falling into this category.

Taken together, this suggests that the rise in pneumonia admissions is related to a genuine rise in more severe cases rather than less severe short stay patients who may be better treated in the community. It is possible that this rise could be linked to improvements in diagnosis of pneumonia and thus improvements in accurate clinical coding. The diagnostic elements of the Enhancing Quality community associated pneumonia pathway could contribute to a systematic rise in pneumonia diagnoses.

The variation between different areas of the region in terms of pneumonia admissions is very clear, as exemplified in figure 12. Of particular interest in this figure is some of the differences between the variation evident in the overall ACS admission rate and that for

Figure 11: Age and gender standardised pneumonia admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

pneumonia only. For example, East Surrey CCG exhibits overall rates well below the England mean (see figure 5) and in the middle of the distribution of CCGs, but the pneumonia admission rates are significantly above the England mean (see figure 12) and in the upper end of the CCG distribution.

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Condition focus: pneumonia

Looking at the breakdown of pneumonia admissions by age and gender shows a distribution that is broadly expected, with admissions rising significantly by age, especially in the over 65 age group and with males consistently showing higher volumes of pneumonia admissions than women in all age groups under 85 (see figure 11). There are three specific points to note from this; firstly there is a small but noticeable peak in the under five age group. Whilst small, with just over 300 admissions in totality, it serves as a reminder that pneumonia is not entirely an issue of the elderly. Secondly, there appears to be a disparity in the 65-69 age

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There are some areas that stand out in terms of having good performance in pneumonia admissions; these high performers could provide lessons for other areas. Of special note is the Guildford and Waverley area which not only shows a relatively low standardised admission rate for pneumonia but, crucially, is the only area throughout Kent, Surrey and Sussex that shows a broadly declining trend in terms of pneumonia admission rates (see figure 13), although this trend has reversed sharply in the most recent year. This is against the increasing trend seen in the region as a whole and in England (see figure 10). Against this, the area does show an increasing trend in length of stay, increasing from the 11-12 days, which is similar to the regional average length of stay, to around 14 days. This may indicate that those patients that are admitted are more severe or complex, and that less acute or severe cases are being treated outside of hospital. This same picture is reflected in the data for the local acute trust, Royal Surrey County Hospital.

group in men, where the relative difference in pneumonia admission volumes between males and females appears to be larger than in other age groups. This may indicate males in this age band being particularly susceptible. Finally, the gender disparity appears reversed in the 85+ age group; this is likely to be purely due to the longer life expectancy of females. There are simply more females in this age band in the general population and so the volume of admissions reflects the nature of the population.

Figure 12: Age and gender breakdown of numbers of pneumonia admissions across KSS, 12 months to November 2013 Figure 13: 12 month rolling pneumonia admission rate per 1,000 for Guildford & Waverley CCG (yellow) vs KSS region (orange)

A question often raised in regard to pneumonia admissions in this context is the extent to which the diagnosis is the primary issue on admission or whether it is secondary to other conditions or problems.

The definitions used here and in the national report by the Nuffield Trust use diagnosis codes in both primary and subsequent to identify cases of pneumonia. Additional analysis of the regional data looking at the split between pneumonia cases identified by primary diagnosis alone and those identified through use of secondary diagnosis code showed that across Kent, Surrey and Sussex 72% of cases are coded with pneumonia as a primary diagnosis. This varies to some extent with a minimum proportion of primary diagnosis pneumonia of 63% and a maximum of 75%. There does not appear to be a relationship between the proportion of pneumonia identified through primary diagnosis and any of the measures analysed.

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Condition focus: urinary tract infections and pyelonephritis

Urinary tract infection (UTI) and pyelonephritis is the most common ACS admission condition accounting for 17% of all ACS admissions, approximately 900 admissions per month, across the region.

It is important to note that this analysis captures UTIs on the basis of primary diagnosis, so patients admitted primarily for other reasons who also have a UTI are not included. This section reviews the trends and variation in UTI/pyelonephritis ACS admissions in more detail.

As with most other ACS conditions, admissions for UTI/pyelonephritis has grown steadily with approximately 31% growth in the rolling 12 month admission rate per 1,000 between March 2007 and November 2013. The growth has been steady over this time period and may be indicative of changing demographics rather than any change in the nature of the disease. This is supported by average length of stay for UTI/ pyelonephritis falling from nine to eight days

Figure 14: Age and gender standardised UTI/ pyelonephritis admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

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The breakdown of admissions for UTI/ pyelonephritis by age is especially interesting. Generally UTI affects females far more than males and this is certainly evident at the younger end of the age distribution, with a definite peak in females in the 15-25 age groups that is not evident for other conditions (see figure 15). However, from 60 years onwards the number of admissions evens out between the genders, with more males than females affected in the 70-74 age group. The pattern still differs from that presented when reviewing all

over the same time period. In addition, the proportion of these admissions with a length of stay of zero is at 1% or less throughout the same time period. This suggests that the complexity of the cases admitted has not changed substantially.

The variation between different areas of the region in terms of UTI/pyelonephritis admissions is very clear, as exemplified in figure 14. Of particular interest in this figure is some of the differences between the variation evident in the overall ACS admission rate and that for UTI/ pyelonephritis only.

For example, North West Surrey CCG exhibits overall rates well below the England mean (see figure 5) and in the middle of the distribution of CCGs, but the UTI/ pyelonephritis standardised admission rates are slightly above the England mean (see figure 14) and in the upper end of the CCG distribution across KSS.

Figure 15: Age and gender breakdown of numbers of UTI/ pyelonephritis admissions across KSS, 12 months to November 2013

ACS admissions (see figure 2) reflecting the greater susceptibility of females to UTIs, but is also supportive of the idea that these admissions are generally for more severe cases; if less severe cases were being admitted not only would the average length of stay be expected to be lower but the differential between males and females in the older age groups would be expected to be much wider.

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Condition focus: urinary tract infections and pyelonephritis

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There are some areas that stand out in terms of having low rates of UTI/ pyelonephritis admissions. Of particular note is the Crawley area which not only shows a standardised admission rate significantly below England but, crucially, is one of only two areas throughout Kent, Surrey and Sussex that shows a relatively flat trend in terms of UTI/pyelonephritis admission rates (see figure 16), the other area being Guildford & Waverley.

Figure 16: 12 month rolling UTI/ pyelonephritis admission rate per 1,000 for Crawley CCG (yellow) vs KSS region (orange) for all age groups

This is against the increasing trend seen in the region as a whole and in England, as discussed above. The average length of stay for UTI/pyelonephritis admissions in Crawley is broadly comparable to the Kent, Surrey and Sussex picture, although there is much more variability evident at the local level, with average length of stay ranging from seven to

Figure 17: 12 month rolling UTI/ pyelonephritis admission rate per 1,000 for Crawley CCG (yellow) vs KSS region (orange) for 0-18 years age group

ten days on average. Crawley also shows an interesting decreasing trend in admission rates per 1,000 for UTI/ pyelonephritis in the under 18s (see figure 17), where there is a definite peak in admissions, especially in females. This may suggest a targeted intervention for this age group in the Crawley area.

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Condition focus: epilepsy and convulsions

It may be tempting to presume that the issue of ACS admissions is one that is exclusive to older age groups with long term conditions and comorbidities that predispose them to regular admissions. Whilst it has been noted above in the review of UTI and pyelonephritis that younger women were also an at risk group, this is predominantly true for most ACS conditions. However, epilepsy and convulsions represents an exception, where the primary age group of concern are the 0-4 year quintile. This section reviews the trends and variation in ACS admissions for epilepsy and convulsions in more detail.

Epilepsy and convulsions are the fourth most common cause of ACS admission, accounting for approximately 5,700 admissions across the region in the year to November 2013.

Figure 18: 12 month rolling epilepsy and convulsions admission rate per 1,000 across all KSS commissioners

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to March 2007, compared to 44% in the year to March 2013, an increase of 18%. If these zero-day length of stay admissions are removed, average length of stay increases to just under 4.5 days, suggesting that there is a polarity of acuity for epilepsy and convulsion admissions, in turn suggesting that a relatively large proportion of ACS admissions for epilepsy and convulsions could be dealt with without the need for admission. Further analysis of this by age group could yield some additional intelligence as to where efforts to reduce these zero length of stay admissions be targeted.

However, the growth in these admissions over the March 2007 to November 2013 period has been relatively small, with 4.8% overall growth, but accompanied by considerable fluctuations in rates over the time period (see figure 18). Length of stay for these admissions has also remained stable at around three days, but across the region more than 30% of these admissions at any point over the time period have a length of stay of zero. This has increased steadily over the time period analysed, with 29% of epilepsy and convulsion admissions with a length of stay of zero in the year to March 2007, compared to 34% in the year to March 2013, an increase of 17%. This is higher in the under 18 age bracket, with 37% of epilepsy and convulsion admissions with a length of stay of zero in the year

Figure 19: Age and gender breakdown of numbers of epilepsy and convulsions admissions across KSS, 12 months to November 2013

The age breakdown of admissions for epilepsy and convulsions is very different from the general profile (see figure 19), with 24% of admissions occurring in the under 10s and a fairly even distribution across the other age groups. The only exception to this is the over 85 age group where the frequency is higher. The gender split generally tends to suggest that males have the greater number of admissions in most age groups (the 85+ age group being an exception, but representative of the general population in this age bracket) and this is particularly evident in the 0-4 years age bracket.

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Condition focus: epilepsy and convulsions

Once again there is significant variation between the CCG areas in terms of admission rates with the pattern comparable to that shown between areas when all ACS admissions are viewed. Hastings & Rother and Thanet are notable for significantly higher than national standardised admission rates for epilepsy and convulsions. There is evidence to suggest that epilepsy incidence increases in line with deprivation

Figure 20: Age and gender standardised epilepsy and convulsions admissions rates per 1,000 for CCGs across KSS, 12 months to November 2013

(e.g. Heaney et al., 2002) therefore this may not come as a surprise in the Kent, Surrey and Sussex context. However Swale CCG is one of the most deprived areas in the region (with a life expectancy of 79.3 years) and yet has a standardised rate of admission per 1,000 for epilepsy and convulsions (see figure 20) statistically significantly lower than the England average.

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Glossary of terms KSS

Kent Surrey and Sussex

ACS

Ambulatory Care Sensitive; conditions for which it is possible to prevent acute exacerbations and reduce the need for hospital admission through active management.

CCG

Clinical Commissioning Group; responsible bodies for implementing the NHS commissioning role as set out in the Health and Social Care Act 2012, made up of groups of GP practices.

LSOA

A geographic hierarchy designed to improve the reporting of small area statistics in England and Wales.

AHSN

Academic Health Science Network

References Blunt, I., (2013), Focus on preventable admissions: Trends in emergency admissions for ambulatory care sensitive conditions, 2001 to 2013, The Health Foundation and the Nuffield Trust, London Billings, J., Zeitel, L., Lukomnik, J., Carey, T., Blank, A. and Newman, L. (1993), Datawatch: impact of socioeconomic status on hospital use in New York city, Health Affairs, 12(1), 162-173 Heaney, MacDonald, Everitt, Stevenson, Leonardi, Wilkinson and Sander (2002), Socioeconomic variation in incidence of epilepsy: prospective community based study in south east England, British Medical Journal, 325, 1010.

Purdy, S., 2010, Avoiding Hospital Admissions; What does the research evidence say?, The King’s Fund, London Tian, Y., Dixon, A. and Gao, H., (2012), Emergency hospital admissions for ambulatory care-sensitive conditions: identifying the potential for reductions, The King’s Fund, London.

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Appendix A: Diagnostic codes used to identify ACS conditions Condition

ICD-10 codes

Acute ACS conditions

Condition

ICD-10 codes

Chronic ACS conditions

Cellulitis

L03, L04, L08, L88, L980, L983 Principal diagnosis only

Angina

I20, I240, I248, I249 Principal diagnosis only

Dehydration

E86 Principal diagnosis only

Asthma

J45, J46 Principal diagnosis only

Dental conditions

A690, K02-K06, K08, K098, K099, K12, K13 Principal diagnosis only

Ear, nose and throat infections

H66, H67, J02, J03, J06, J312 Principal diagnosis only

Chronic obstructive pulmonary disease

J20, J41-J44, J47 Principal diagnosis only, J20 only with diag2 of J41 J42 J43 J44 J47

Gangrene

R02 Any diagnosis

Congestive heart failure

I110, I50, J81 Principal diagnosis only

Gastroenteritis

A099, K522, K528, K529 Principal diagnosis only

Convulsions and epilepsy

G40, G41, O15, R56 Principal diagnosis only

Nutritional deficiencies

E40-E43, E55, E643 Principal diagnosis only

Diabetes complications

E100-E108, E110-E118, E120-E128, E130-E138, E140-E148 In any diagnosis field

Pelvic inflammatory disease

N70, N73, N74 Principal diagnosis only

Hypertension

I10, I119 Principal diagnosis only

Perforated/bleeding ulcer

K250-K252, K254-K256, K260-K262, K264-K266, K270-K272, K274-K276, K280-K282, K284-K286 Principal diagnosis only

Iron deficiency anaemia

D501,D508,D509 Principal diagnosis only

Urinary tract infection/Pyelonephritis

N10, N11, N12, N136, N390 Principal diagnosis only

Other and Vaccine preventable ACS conditions Influenza

J10, J11 In any diagnosis field, excludes cases with secondary diagnosis of D57, and people under 2 months

Pneumonia

J13, J14, J153, J154, J157, J159, J168, J181, J188 In any diagnosis field, excludes cases with secondary diagnosis of D57, and people under 2 months

Tuberculosis

A15, A16, A19 Principal diagnosis only

Other vaccine preventable

A35-A37, A80, B05, B06, B161, B169, B180, B181, B26, G000, M014 In any diagnosis field

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Appendix B: Tool screenshots

First Floor Wentworth House Crawley Hospital West Green Drive Crawley West Sussex RH11 7DH 0300 303 8660 enquiries@kssahsn.net www.kssahsn.net