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Original article
Contribution of recurrent admissions in children and young people to emergency hospital admissions: retrospective cohort analysis of hospital episode statistics Linda PMM Wijlaars,1 Pia Hardelid,1 Jenny Woodman,1 Janice Allister,2 Ronny Cheung,3 Ruth Gilbert1 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ archdischild-2014-307771). 1
Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK 2 Clinical Innovation and Research, Royal College of General Practitioners, London, UK 3 Department of General Paediatrics, Evelina’s Children Hospital, Guy’s and St Thomas’ NHS Trust, London, UK Correspondence to Dr Linda Wijlaars, Population, Policy and Practice Programme, UCL Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; [email protected] Received 22 October 2014 Revised 20 April 2015 Accepted 23 April 2015 Published Online First 18 May 2015
ABSTRACT Objective To examine the contribution of recurrent admissions to the high rate of emergency admissions among children and young people (CYP) in England, and to what extent readmissions are accounted for by patients with chronic conditions. Design All hospital admissions to the National Health Service (NHS) in England using hospital episode statistics (HES) from 2009 to 2011 for CYP aged 0–24 years. We followed CYP for 2 years from discharge of their first emergency admission in 2009. We determined the number of subsequent emergency admissions, time to next admission, length of stay and the proportion of injury and chronic condition admissions measured by diagnostic codes in all following admissions. Results 869 895 children had an index emergency admission in 2009, resulting in a further 939 710 admissions (of which 600 322, or 64%, were emergency admissions) over the next 2 years. After discharge from the index admission, 32% of 274,986 (32%) children were readmitted within 2 years, 26% of these readmissions occurring within 30 days of discharge. Recurrent emergency admission accounted for 41% of all emergency admissions in the 2-year cohort and 66% of inpatient days. 41% of index admissions, but 76% of the recurrent emergency admissions, were in children with a chronic condition. Conclusions Recurrent admissions contribute substantially to total emergency admissions. They often occur soon after discharge, and disproportionately affect CYP with chronic conditions. Policies aiming to discourage readmissions should consider whether they could undermine necessary inpatient care for children with chronic conditions.
INTRODUCTION
To cite: Wijlaars LPMM, Hardelid P, Woodman J, et al. Arch Dis Child 2015;100:845–849.
Over the past 10 years, the number of emergency hospital admissions (admissions that are not planned and happen at short notice because of perceived clinical need) in children and young people (CYP) has increased year-on-year.1 2 This increase has been driven mainly by short-term admissions, with a twofold increase in admissions that lasted less than 1 day between 1999 and 2010 while the total admission rate increased by only 28%.1 3 These results could imply that admissions have become progressively shorter over time, or that short admissions (eg, to paediatric assessment units) have become more prevalent. Another
What is already known on this topic? ▸ Rates of emergency hospital admissions have been increasing year-on-year in children and young people (CYP). ▸ A substantial proportion (one in five) of emergency admissions is considered to be avoidable, especially those involving short-stay admissions.
What this study adds? ▸ Of CYP requiring emergency admission to hospital, 32% had at least one recurrent emergency admission within 2 years. Recurrent emergency admissions accounted for 41% of all emergency admissions and 66% of emergency bed days. ▸ Emergency admissions recurred soon after discharge with one in four recurrent admissions occurring within 30 days. ▸ Recurrent emergency admissions occurred overwhelmingly in CYP affected by chronic conditions.
possible explanation could be an increase in recurrent admissions: when CYP’s holistic health needs were not properly addressed during progressively shorter admissions, this could lead to further emergency admissions. Interventions are needed to reduce the need for emergency admissions and ensure that patients are treated in the most appropriate setting.3–5 National policy initiatives include financial incentives, such as the 30-day emergency readmission rule, which partially redirects funds previously accrued by hospitals for emergency admissions to be reinvested by National Health Service (NHS) commissioners into specific joint activities that aim to reduce the demand on emergency services.6 However, there is a lack of evidence about the extent to which recurrent admissions account for the high and increasing rates of admission in children. Recent research has focused on identifying which admissions are potentially avoidable.1 2 One study,
Wijlaars LPMM, et al. Arch Dis Child 2015;100:845–849. doi:10.1136/archdischild-2014-307771
845
Downloaded from http://adc.bmj.com/ on August 20, 2015 - Published by group.bmj.com
Original article focusing on ambulatory care sensitive conditions, has estimated that approximately 20% of emergency are preventable,7 but has not considered admission patterns of CYP over time. The contribution of underlying chronic conditions has also not been determined.1 8 As hospital care is expensive and strains resources, identifying characteristics of patients who are recurrently admitted could inform preventative and cost-reducing measures. We used national hospitalisation data from 2009 to 2012 to determine the proportion of emergency admissions in CYP that are recurrent, how soon after discharge admissions recurred, and what proportion of admissions were accounted for by CYP affected by chronic conditions.
METHODS Data source We analysed hospital admissions to the NHS in England using hospital episode statistics (HES)9 from April 2009 to March 2012 for CYP aged 0–24 years. The HES database records all inpatient admissions, including day cases, to the NHS in England. We tracked patients longitudinally using a unique identifier (HES-ID), which is derived by the Health & Social Care Information Centre from the patient’s NHS number, postcode, date of birth and sex.10
Population A detailed description of how we identified admissions is given in online supplementary appendix A. We identified admissions as continuous periods in hospital that could consist of several episodes ( period of hospital stay under a single consultant). We considered admissions that occurred within a day of each other and admissions that included a transfer as a single admission.11 CYP were included if they had a valid recording of sex, and were aged up to 24 years. Analyses were stratified by age groups (
Original article
Contribution of recurrent admissions in children and young people to emergency hospital admissions: retrospective cohort analysis of hospital episode statistics Linda PMM Wijlaars,1 Pia Hardelid,1 Jenny Woodman,1 Janice Allister,2 Ronny Cheung,3 Ruth Gilbert1 ▸ Additional material is published online only. To view please visit the journal online (http://dx.doi.org/10.1136/ archdischild-2014-307771). 1
Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK 2 Clinical Innovation and Research, Royal College of General Practitioners, London, UK 3 Department of General Paediatrics, Evelina’s Children Hospital, Guy’s and St Thomas’ NHS Trust, London, UK Correspondence to Dr Linda Wijlaars, Population, Policy and Practice Programme, UCL Institute of Child Health, 30 Guildford Street, London WC1N 1EH, UK; [email protected] Received 22 October 2014 Revised 20 April 2015 Accepted 23 April 2015 Published Online First 18 May 2015
ABSTRACT Objective To examine the contribution of recurrent admissions to the high rate of emergency admissions among children and young people (CYP) in England, and to what extent readmissions are accounted for by patients with chronic conditions. Design All hospital admissions to the National Health Service (NHS) in England using hospital episode statistics (HES) from 2009 to 2011 for CYP aged 0–24 years. We followed CYP for 2 years from discharge of their first emergency admission in 2009. We determined the number of subsequent emergency admissions, time to next admission, length of stay and the proportion of injury and chronic condition admissions measured by diagnostic codes in all following admissions. Results 869 895 children had an index emergency admission in 2009, resulting in a further 939 710 admissions (of which 600 322, or 64%, were emergency admissions) over the next 2 years. After discharge from the index admission, 32% of 274,986 (32%) children were readmitted within 2 years, 26% of these readmissions occurring within 30 days of discharge. Recurrent emergency admission accounted for 41% of all emergency admissions in the 2-year cohort and 66% of inpatient days. 41% of index admissions, but 76% of the recurrent emergency admissions, were in children with a chronic condition. Conclusions Recurrent admissions contribute substantially to total emergency admissions. They often occur soon after discharge, and disproportionately affect CYP with chronic conditions. Policies aiming to discourage readmissions should consider whether they could undermine necessary inpatient care for children with chronic conditions.
INTRODUCTION
To cite: Wijlaars LPMM, Hardelid P, Woodman J, et al. Arch Dis Child 2015;100:845–849.
Over the past 10 years, the number of emergency hospital admissions (admissions that are not planned and happen at short notice because of perceived clinical need) in children and young people (CYP) has increased year-on-year.1 2 This increase has been driven mainly by short-term admissions, with a twofold increase in admissions that lasted less than 1 day between 1999 and 2010 while the total admission rate increased by only 28%.1 3 These results could imply that admissions have become progressively shorter over time, or that short admissions (eg, to paediatric assessment units) have become more prevalent. Another
What is already known on this topic? ▸ Rates of emergency hospital admissions have been increasing year-on-year in children and young people (CYP). ▸ A substantial proportion (one in five) of emergency admissions is considered to be avoidable, especially those involving short-stay admissions.
What this study adds? ▸ Of CYP requiring emergency admission to hospital, 32% had at least one recurrent emergency admission within 2 years. Recurrent emergency admissions accounted for 41% of all emergency admissions and 66% of emergency bed days. ▸ Emergency admissions recurred soon after discharge with one in four recurrent admissions occurring within 30 days. ▸ Recurrent emergency admissions occurred overwhelmingly in CYP affected by chronic conditions.
possible explanation could be an increase in recurrent admissions: when CYP’s holistic health needs were not properly addressed during progressively shorter admissions, this could lead to further emergency admissions. Interventions are needed to reduce the need for emergency admissions and ensure that patients are treated in the most appropriate setting.3–5 National policy initiatives include financial incentives, such as the 30-day emergency readmission rule, which partially redirects funds previously accrued by hospitals for emergency admissions to be reinvested by National Health Service (NHS) commissioners into specific joint activities that aim to reduce the demand on emergency services.6 However, there is a lack of evidence about the extent to which recurrent admissions account for the high and increasing rates of admission in children. Recent research has focused on identifying which admissions are potentially avoidable.1 2 One study,
Wijlaars LPMM, et al. Arch Dis Child 2015;100:845–849. doi:10.1136/archdischild-2014-307771
845
Downloaded from http://adc.bmj.com/ on August 20, 2015 - Published by group.bmj.com
Original article focusing on ambulatory care sensitive conditions, has estimated that approximately 20% of emergency are preventable,7 but has not considered admission patterns of CYP over time. The contribution of underlying chronic conditions has also not been determined.1 8 As hospital care is expensive and strains resources, identifying characteristics of patients who are recurrently admitted could inform preventative and cost-reducing measures. We used national hospitalisation data from 2009 to 2012 to determine the proportion of emergency admissions in CYP that are recurrent, how soon after discharge admissions recurred, and what proportion of admissions were accounted for by CYP affected by chronic conditions.
METHODS Data source We analysed hospital admissions to the NHS in England using hospital episode statistics (HES)9 from April 2009 to March 2012 for CYP aged 0–24 years. The HES database records all inpatient admissions, including day cases, to the NHS in England. We tracked patients longitudinally using a unique identifier (HES-ID), which is derived by the Health & Social Care Information Centre from the patient’s NHS number, postcode, date of birth and sex.10
Population A detailed description of how we identified admissions is given in online supplementary appendix A. We identified admissions as continuous periods in hospital that could consist of several episodes ( period of hospital stay under a single consultant). We considered admissions that occurred within a day of each other and admissions that included a transfer as a single admission.11 CYP were included if they had a valid recording of sex, and were aged up to 24 years. Analyses were stratified by age groups (
