The Cost of Insulin-dependent Diabetes Mellitus (IDDM) in England and Wales

This study estimates the direct health and social care costs of insulin-dependent diabetes mellitus (IDDM) in England and Wales in 1992 to be £96 million, or £1021 per person in a population with IDDM estimated at 94 000 individuals. These costs include insulin maintenance, hospitalization, GP and out-patient consultations, renal replacement therapy, and payments to informal carers. Expenditure is concentrated on younger age groups, with one-third of the total expended on those aged 0–24. Around one-half of the total costs can be directly attributed to IDDM, with the remainder associated with a range of complications of the disease. The single largest area of service expenditure is renal replacement therapy. The cost estimates are most sensitive to incidence rates of IDDM, numbers on dialysis and average duration of dialysis. A further £113 million pounds may be lost each year due to premature deaths resulting in lost productive contributions to the economy. The direct and indirect costs of IDDM are therefore significant. The cost of illness framework presented here should facilitate the economic evaluation of new and existing treatment regimens, which may improve value for money by reducing costs and/or increasing the quality or quantity of life for people with IDDM.     

Association between general practice funding and practice achievement: a cross-sectional study

BackgroundIn the past decade, general practice funding has decreased from 11% to 8% of total National Health Service (NHS) spending, while workload has increased by 19%. To date, the impact of broader aspects of practice funding on performance has not been examined. Using newly released primary care financial data, we aimed to explore the association between NHS payments made to general practices in England that are not part of the quality and outcomes framework (QOF) and primary care performance.MethodsPractice funding data were extracted from the National Health Applications and Infrastructure Services. We confined our analysis to practices with the nationally determined contract, General Medical Services (n=4298); data were not available for the locally determined contracts offered to Personal Medical Services practices. We constructed regression models to explore the association between practice funding and QOF outcomes, secondary care usage (outpatient, accident and emergency [A&E], and inpatient rates per 1000 registered patients), and patient satisfaction, adjusted for practice and demographic variables. We then conducted financial modelling to predict the impact of a hypothetical 10% funding increase on secondary care costs, for which we used standard cost estimates.FindingsThe mean funding was £75·71 per patient (95% CI 66·86–87·58). Higher funding was significantly associated with lower emergency admissions (regression coefficient β=0·24), lower A&E attendances (−1·04), and higher patient satisfaction (overall satisfaction 0·002). We found no significant association with outpatient attendance or QOF performance. In our financial model, a 10% increase in primary care funding would cost an additional £7571 per 1000 registered patients, which would be partly offset by a £5323 reduction in emergency admissions and £1031 reduction in A&E attendances.InterpretationGeneral Medical Services practices with higher levels of funding had lower secondary care usage and higher patient satisfaction. The lack of association between funding and QOF achievement might be attributable to the different funding stream and incentives for QOF. Our findings support the case for greater investment in primary care which would largely be offset by reduced secondary care costs and associated with higher levels of patient satisfaction.FundingVSL is funded by a National Institute for Health Research academic clinical fellowship.     

Trajectory of achievement in primary school and development of mental health conditions in adolescence: a cohort study using linked health and education data

BackgroundLittle is known about how mental health in primary school affects subsequent adolescent mental health. This study examined the effect of education in primary school on development of mental health conditions.MethodsThis cohort study of all children in Wales between 1999 and 2014 used routine data from general practice and hospital data linked with education records held in the Secure Anonymised Information Linkage (SAIL) databank. Cox regression was used, controlling for sex, deprivation, conduct disorder, attention deficit hyperactivity disorder, and learning difficulty.FindingsHealth records of 652 903 children (319 839 boys, 307 584 girls) were linked with educational records: between the ages of 12 and 21 years, 33 498 children (5·1%) developed depression, 15 946 (2·4%) self-harmed, and 2183 (0·3%) had eating disorders. 10 458 boys (3·2%) and 23 040 girls (7·5%) had diagnosed depression during their childhood, and 10 550 boys (3·3%) and 21 278 girls (6·9%) were given an antidepressant. Children who developed depression were more likely than those not developing depression to have passed key stage 1 (age 7 years) (adjusted hazard ratio [HR] 1·19, 95% CI 1·08–1·30) but not key stage 2 (age 11) (0·76, 0·69–0·83), indicating that they were declining in primary school education. Conversely those who self-harmed (4736 boys [1·5%], 11 210 girls [3·6%]) were achieving as well as those who did not self-harm (1·02, 0·92–1·12). In children with an eating disorder, only female sex was associated with development of the disorder (10·5, 7·55–14·5), and educational achievement was not significantly different from those without the disorder (1·16, 0·82–1·63). However, at key stage 3 (age 14) children with eating disorders achieved well in secondary school (1·42, 1·2–1·7).InterpretationThe trajectory of achievement in primary school is very different for children who develop depression, self-harm, or eating disorders. Those who developed depression were deprived children declining in primary school education; those who self-harmed were deprived children improving in primary educational achievement. However, eating disorders were not associated with education or deprivation in primary school but associated with high achievement in secondary school.FundingNational Centre for Population Health and Wellbeing Research.     

Resource Use and Costs up to Two Years Post Diagnosis Among Newly Diagnosed COPD Patients in the UK Primary Care Setting: A Retrospective Cohort Study

The objective of this study was to estimate the annual resource use and costs before and after COPD diagnosis and compare it across stages of airflow obstruction and levels of dyspnoea in the UK primary care setting. A retrospective cohort of newly diagnosed COPD patients (1/1/2008-31/12/2009) was identified in the UK Clinical Practice Research Datalink (CPRD). Resource use did not include medication costs and comprised of exacerbations, all cause GP interactions, and non-COPD hospitalisations, which were estimated for up to 12 months before and 24 months after COPD diagnosis. It was further stratified using baseline characteristics, Medical Research Council (MRC) dyspnoea score, and stages of airflow limitation. COPD costs were estimated using NHS reference costs. The analysis included 7881 newly diagnosed COPD patients (mean age, 67.2 years; 45% females). In the 2 years follow-up, the cohort experienced moderate and severe exacerbations, non-COPD hospitalisations, and GP surgery visits at an annual rate of 0.51, 0.13, 0.47, and 12.85, respectively. All resource components showed an upward trend with increase airflow limitation and dyspnoea. GP interactions accounted for 58.5% of annual per patient COPD management costs, estimated to be £2047 during the observation period. The annual costs doubled from patients with low levels of dyspnoea (MRC = 1; £1473) to those with high levels of dyspnoea (MRC = 5; £3243). COPD management costs in the primary care setting continued to remain high up to 2 years following initial diagnosis. The cost burden increased with high levels of dyspnoea and airflow obstruction, suggesting that both measures can identify patients requiring increased monitoring.     

Patient and health-care factors associated with potentially missed acute deterioration in primary care: a retrospective observational study of linked primary and secondary care data

BackgroundIn the UK, the majority of patient contact with health services occurs in primary care. Most of these contacts are uncomplicated; however, patient safety incidents (eg, failure to recognise patient deterioration) can occur. We aimed to explore patient and health-care factors associated with a self-referred admission, in patients with deteriorating health who consulted a general practitioner (GP).MethodsIn this observational study, we identified patients who had consulted a GP in the 3 days before an unplanned admission (indication of deterioration) between April 1, 2014, and Dec 31, 2017, in England, using the Clinical Practice Research Datalink with linkage to inpatient hospital admissions and emergency department data. We applied a multivariable, multilevel logistic regression model (generalised estimating equations) to investigate factors associated with self-referral (ie, patient age and existing health conditions, GP consultation, deteriorating health condition, and previous health service use) compared with other-referred unplanned admissions (eg, GP-referrals). Self-referred admission, as a composite measure, was defined as an unplanned admission via the emergency department (inpatient data) recorded as a self-referral in the corresponding emergency department record. We investigated all diagnoses and a subset of commonly reported missed conditions: sepsis, pulmonary embolism, urinary tract infections, and ectopic pregnancies in women.FindingsOf 405 878 unplanned admissions, 116 094 (28%) patients had contact with a GP 3 days before admission. The proportion of self-referred admissions varied by region (4189 [31%] of 13 639 inpatient admissions in London vs 1721 [12%] of 14 641 inpatient admissions in south west England), age, deteriorating health, and existing health conditions. Patients with sepsis or a urinary tract infection were more likely to self-refer than patients with other conditions (adjusted odds ratio [OR] 1·10, 95% CI 1·02–1·19 for sepsis; 1·09, 1·04–1·14, for urinary tract infection). GP appointment length was associated with a self-referred admission: a 5 min increase in consultation duration decreased the risk of self-referral by 6% (OR 0·94, 0·91–0·97). Telephone consultations, comorbidity, and previous health service use were also associated with self-referred admission.InterpretationDifferentiating deterioration from self-limiting conditions is difficult for GPs, particularly in patients with sepsis, urinary tract infections, or long-term conditions. The negative association between GP consultation duration and self-referral supports demand for longer GP consultations. However, more research is needed to investigate the underlying mechanism between GP consultation time and referral.FundingNational Institutes for Health Research.     

Choosing between different alcohol pricing and taxation strategies: a comparative policy appraisal using the Sheffield Alcohol Policy Model

BackgroundPolicies that increase alcohol prices effectively reduce alcohol consumption, one of the top three risk factors for global disease burden. Our aim was to appraise how different alcohol pricing policies balance competing priorities.MethodsWe built an econometric dynamic epidemiological model for England, combining survey and register data on alcohol purchasing, consumption, and 43 harms, and published price elasticities, relative risk, and alcohol attribution. We model five hypothetical taxation options each estimated to give a 10% reduction in average consumption: P1, a uniform 85% increase in existing duty; P2, a 22% sales tax based on product price; P3, a £0·35 per unit volumetric tax; P4, a £0·80 minimum unit price (MUP); P5, a £0·75 MUP with a volumetric tax of £0·30. Outcomes were consumption, annual alcohol-related deaths, hospital admissions, health-care costs, consumer spending, and government revenue. Uncertainty was assessed through sensitivity analyses.FindingsPopulation level health harm-reductions would be highest for increases in the present tax system (P1: deaths ?3026, hospital admissions ?179 000, health-care costs ?£583 million) and for the MUP (P4: ?3081, ?169 000, ?£574 million), and lowest for the sales tax (P2: ?2852, ?168 000, ?£575 million). Harm reductions in high-risk drinkers would be highest for the two MUP options (P4: deaths ?1764, hospital admissions ?84 000, health care ?£218 million; P5: ?1712, ?78 000, ?£205 million), and lowest for sales tax (P2: ?1267, ?64 000, ?£159 million). The overall greatest burden on consumer spending would be from a duty increase under the present system (P1 £3·2 million), and the lowest from a volumetric tax (P3 £2·0 million). The smallest extra annual expenditure for each moderate drinker would be achieved by MUP (P4 £17·80), whereas the largest extra expenditure would be from a tax rise in the present system (P2 £37·20). With the exception of the MUP-only policy, which would have a small negative effect on government revenue from alcohol (P4: 1·3%, ?£121 million), all taxation policies would raise government revenue, by between £1·9 billion and £4·2 billion per year.InterpretationPricing policies can be implemented in ways that balance the priorities of increasing government revenue, maximising harm reductions, and targeting heavy drinkers, while protecting moderate consumers from excessive burden.FundingMedical Research Council and Economic and Social Research Council (grant G1000043).     

Association between the arrested decline in cardiovascular disease and health and social-care costs: a modelling study

BackgroundDementia and cardiovascular disease generate enormous health and social-care costs and have shared risk factors. Following decades of cardiovascular disease mortality declines in England, improvements slowed after 2011. We investigated the potential economic implications of this slowdown.MethodsWe used the IMPACT better aging model—an open-cohort, stochastic Markov model. We synthesised trends in cardiovascular disease incidence and mortality, dementia, and disability (defined as reported diagnosis, functional impairment, or measured cognitive impairment) from the English Longitudinal Study of Ageing (ELSA) and Office for National Statistics data. We projected trends for adults aged 35–100 years in England and Wales from 2019–29. We modelled undiscounted health and social-care costs (primary outcome), and quality-adjusted life-years (QALYs) under the following two scenarios: age-specific cardiovascular disease incidence continues to decline, recommencing previous downward trends (scenario one); or age-specific cardiovascular disease incidence plateaus after 2006, continuing recent trends, assuming changes in mortality reflect incidence 5 years before (scenario two). We linked 85% of ELSA participants to their Hospital Episode Statistics (HES) data, which were costed and calibrated to national estimates. Age-related social-care costs were estimated by use of reported contact hours from ELSA combined with standard reference costs. Standard catalogues were used for QALY weights.FindingsIn scenario one, changes in population size and health were projected to increase health-care costs by around 12% between 2019 and 2029, from £93·0 billion to £104·6 billion per year (in 2019 prices). Social-care costs were projected to increase by around 27%, from £8·0 billion to £10·2 billion per year. In scenario two, health-care costs were projected to increase by around 15%, from £95·3 billion to £109·6 billion, and social-care costs by around 30%, from £8·2 billion to £10·7 billion, between 2019 and 2029. The overall net monetary cost of this slowdown in cardiovascular disease decline was £17·5 billion per year (made up of 200 000 QALYs and £5·5 billion in health and social-care costs).InterpretationWe predict social-care costs will grow twice as fast as health-care costs over the next decade, even if cardiovascular disease occurrence continues to decline. Understanding the scale of the future health and social-care funding challenge might support proactive policy making. This study represents the first time ELSA data have been linked with HES data. However, we did not assess changes in health and social-care efficiency over time or the effect of spending on improving health.FundingBritish Heart Foundation     

Patterns and costs of hospital care for coronary heart disease related and not related to diabetes

Objective—To describe the epidemiology and costs of coronary heart disease (CHD) requiring hospital admission, with particular reference to diabetes.
Setting—The former South Glamorgan Health Authority, South Wales.
Methods—Routine hospital activity data were record linked and all diabetic and non-diabetic individuals over a four year period (1991-95) were identified. A cost weight was included for each admission based on diagnosis related groups.
Results—There were 10 214 patients admitted with a primary diagnostic code for CHD, representing an incidence of 6.3 per 1000 per annum. Including all CHD and non-CHD admissions, these individuals were responsible for 17% of acute inpatient activity. Men had a consistently higher age specific prevalence of CHD than women. The age adjusted relative risk of CHD for patients with diabetes compared with those without was 4.1 for men and 5.5 for women. Patients with diabetes accounted for 16.9% of CHD related admissions and had a fourfold increased probability of undergoing a cardiac procedure. The total cost of CHD was estimated to be 6% of NHS revenue at 1994-95 pay and prices. Patients with diabetes were responsible for 16% of this expenditure. This translated to an estimated NHS acute hospital expenditure for CHD of £1.1 billion per year at 1994-95 pay and prices.
Conclusions—CHD was responsible for a larger proportion of NHS expenditure than had previously been reported. Nearly one in five acute hospital admissions were for patients whose condition included cardiac problems. The relation between diabetes and CHD was particularly evident, and may offer opportunities for disease prevention.

Keywords: coronary heart disease;  diabetes mellitus;  cost and cost analysis;  epidemiology     

Health and social care costs at the end of life: a cross-sectional matched analysis of linked patient records in East London

BackgroundAfter a decade of austerity, controlling costs in the health system while addressing the needs of a growing population is one of the most pressing health policy objectives in England. Care in the final year of life accounts for 10% of inpatient hospital costs in England, but there has been scarce analysis of end-of-life costs in other care settings. We aimed to investigate the publicly funded costs associated with end-of-life care across different health and social care settings.MethodsWe did a cross-sectional analysis of linked electronic health records of residents aged over 50 years in a borough in East London, between 2011 and 2017. Individuals who died during the study period were matched to survivors on age group, sex, deprivation status by area of residence, number of long-term conditions, and time period. We calculated costs in the final year of life as the mean difference in costs between paired survivors and decedents, with bootstrapped CIs and significance testing via the Wilcoxon signed-rank test. We further disaggregated costs by care setting, age, and months to death. Study approval was provided by the Barking and Dagenham, Havering, and Redbridge Information Governance Steering Committee.FindingsAcross 8720 matched patients, the final year of life was associated with an increase in mean costs of £7450 (95% CI 7086–7842, p<0·001), £4218 (57%) of which was due to unplanned hospital care. Although costs increased sharply over the final few months of life in emergency and inpatient hospital care, costs in non-acute settings were less concentrated in this period. After adjustment by time-to-death, social care costs increased with age, while health-care costs decreased.InterpretationThere is a large increase in costs in the final year of life, most of which relate to unplanned hospital care, suggesting that better end-of-life planning might lead to cost savings. Social care costs, unlike health-care costs, increase with age after accounting for time-to-death. As such, an ageing population places more pressure on the social care system.FundingNone.     

Exploring the case for investing in early years in Wales: a broad evidence review

BackgroundLife-expectancy and healthy life-expectancy depend on the socioeconomic and wider determinants of health. At birth there is an 18·9 year difference in healthy life expectancy between the least and most deprived areas of Wales. Multidisciplinary public health policy requires that prevention interventions are increasingly assessed in terms of the financial return on investment. The aim of this study was to explore the return on investment of a broad range of early years' interventions, where possible applied to the context of Wales.MethodsWe constructed a pragmatic framework to explore international and UK evidence on the relative return on investment of: devoting public sector resources to programmes and practices that support babies and young children (up to age 7 years), and their families; promoting skills development through education; and fostering positive environments that protect health assets relevant to the early years. This review was not done systematically because of the breadth of interventions considered. Rather, we used snowballing to search for literature starting with centres of excellence in the USA and UK, and recent key policy reports. We restricted our search to studies published in English during the past 20 years.FindingsWe identified estimates of return on investment, mainly from the USA and UK, from investment in the child and whole family, education and skills, and a child's environment and wider community. Methods of calculating return on investment were not standardised so comparisons across programmes were problematic. We found evidence that for every £1 spent on contraceptive services between £11 and £14 in savings could be returned annually to the National Health Service (NHS) in Wales. We estimate that increasing the proportion of women who exclusively breastfeed at 4 months (presently 9% in Wales) to that recorded at birth (57%) could save the NHS in Wales £1·5 million annually in treating common early childhood diseases. Our finding that every £1 invested in adventure playgrounds could provide a return on investment of £1·32 shows the importance of physical activity and play.InterpretationThere are efficiency and equity arguments for investing in early years. Investment in early years should be considered in the same way as investment in the wider economic development across the Welsh economy.FundingPublic Health Wales.     

Impella Versus Extracorporeal Membrane Oxygenation for Acute Myocardial Infarction Cardiogenic Shock

BackgroundPercutaneous ventricular assist devices and extracorporeal membrane oxygenation (ECMO) are increasingly used for mechanical circulatory support (MCS) in patients with acute myocardial infarction with cardiogenic shock (AMI-CS) in hospitals throughout the United States.MethodsUsing the National Inpatient Sample from October 2015 to December 2017, we identified hospital admissions that underwent percutaneous coronary intervention (PCI) and non-elective Impella or ECMO placement for AMI-CS using ICD-10 codes. Propensity-score matching was performed to compare both groups for primary and secondary outcomes.ResultsWe identified 6290 admissions for AMI-CS who underwent PCI and were treated with Impella (n = 5730, 91%) or ECMO (n = 560, 9%) from October 2015 to December 2017. After propensity-match analysis, the ECMO cohort had significantly higher in-hospital mortality (43.3% vs 26.7%, OR: 2.10, p = 0.021). The incidence of acute respiratory failure and vascular complications were significantly lower in the Impella cohort. We observed a shorter duration of hospital stay and lower hospital costs in the Impella cohort compared to those who received ECMO.ConclusionsIn AMI-CS, the use of Impella was associated with better clinical outcomes, fewer complications, shorter length of hospital stay and lower hospital cost compared to those undergoing ECMO placement.     

Mortality in adults with learning disabilities with and without a health check: a cohort study

BackgroundAnnual health checks in primary care were introduced in Wales in 2006, for adults with learning disability on the social services register. The health check includes screening for conditions such as diabetes, general health measures, and medication review. We aimed to compare mortality rates in individuals who have a health check and those with no record of having a health check in their medical records.MethodsWe stratified general practice records of 24 474 people with a learning disability in Wales by health check status (read code for a health check vs no health check). The Secure Anonymised Data Linkage databank was used to link general practitioner (GP) data and Office for National Statistics mortality data between Jan 1, 2005, and Dec 31, 2017. We used survival analysis (Cox's regression) to calculate unadjusted and adjusted (for age, sex, and comorbidity) mortality hazard ratios (HRs).FindingsOf the 24 474 people with a learning disability in Wales, 7542 (30·8%) had a confirmed health check and 16 932 (69·2%) had no record of a health check. Mortality rates were higher for people with a learning disability who have never received a health check than those who had received a health check (3·55 deaths per 1000 individuals per year in the non-health check group vs 2·08 deaths per 1000 individuals in the health check group). Among individuals with autism, mortality was lower among individuals who had a health check than those who had no check (HR 0·61, 95% CI 0·39–0·96; adjusted HR 0·53, 0·33–0·83 [adjusted for age and sex]). Among individuals with epilepsy, mortality was also lower among individuals who had a health check than those who had no check (HR 0·72, 0·64–0.81; adjusted HR 0·65, 0·58–0·74 [adjusted for age and sex]) and the same trend was observed among individuals with diabetes (HR 0·77, 0·64–0·92; adjusted HR 0·71, 0·60–0·84). The largest differences in mortality between individuals with and without a health check were observed among individuals aged 18-50 years (adjusted HR 0·46, 0·39–0·50 [adjusted for comorbidity and sex]), with a smaller difference in mortality identified among individuals aged older than 50 years at their first health check (adjusted HR 0·81, 0·72–0·90 [adjusted for comorbidity and sex]).InterpretationMortality is lower among people with learning disabilities who have health checks than those who do not. Our findings suggest that health checks provide long-term benefit, especially for younger people.FundingWelsh Assembly Government.     

Effects of national housing quality standards on hospital emergency admissions: a quasi-experiment using data-linkage

BackgroundNational housing quality standards are now being applied throughout the UK. The Welsh Government has introduced the Welsh Housing Quality Standards. A housing improvement programme in Wales has been delivered through one local authority to bring 9500 homes up to standard. Homes received multiple elements, including new kitchens, bathrooms, windows and doors, boilers, insulation, and wiring, through an 8 year rolling work programme. The study aimed to determine the impacts of the different housing improvements on hospital emergency admissions for residents over 60 years of age.MethodsIntervention homes (council homes that received at least one element of work) were data linked to individual health records of residents. Counts of admissions for respiratory and cardiovascular conditions, and for falls and burns, were obtained retrospectively for each individual in a dynamic housing cohort (Jan 1, 2005, to March 31, 2015). The criterion for the intervention cohort was for someone to have lived in any one of the 9500 intervention homes for at least 3 months within the intervention period. Counts were captured for up to 123 consecutive months for 7054 individuals in the intervention cohort and analysed in a multilevel approach to account for repeated observations for individuals, nested within geographical areas. Negative binomial regression models were constructed to determine the effect on emergency admissions for those living in homes compliant for each element of work compared with those living in homes that were non-compliant at that time. We adjusted for background trends in the regional general population, and for other confounding factors.FindingsFor residents 60 years old and over there was a reduction in admissions for people with compliant boilers (rate ratio 0·71, 95% CI 0·67–0·76), loft insulation (0·87, 0·80–0·95), wall insulation (0·74, 0·69–0·80), and windows and doors (0·56, 0·52–0·61) compared with those living in homes that were non-compliant for those work elements.InterpretationImproving housing to national standards reduces the number of emergency admissions to hospital for older residents. Strengths of the data-linkage approach included the retrospective collection of complete baseline and follow-up data using routine data for a long-term intervention, and large scale regional adjustment.FundingNational Institute for Health Research (NIHR) Public Health Research programme (project number 09/3006/02).     

Social return on investment analysis of a physiotherapy-led service for managing osteoarthritis in primary care

Background

Over 8·75 million people in the UK live with osteoarthritis, which has major social and economic costs. Although the current approach to managing this condition in primary care is suboptimal, any quality improvement must deliver value for money. Social return on investment (SROI) is a cost-benefit analysis that captures wider social benefits. Here, we describe a SROI analysis of a physiotherapy-led service (rather than the usual general practitioner [GP]-led model) delivering National Institute for Health and Care Excellence (NICE) guidance for managing osteoarthritis in six GP practices.

The Financial Impact of a Partnership Between an Academic Medical Center and a Free Clinic

PurposeThe objective of this study is to examine the association between an academic medical center and free clinic referral partnership and subsequent hospital utilization and costs for uninsured patients discharged from the academic medical center's emergency department (ED) or inpatient hospital.MethodsThis retrospective, cross-sectional study included 6014 uninsured patients age 18 and older who were discharged from the academic medical center's ED or inpatient hospital between July 2016 and June 2017 and were followed for 90 days in the organization's electronic medical record to identify the occurrence and cost of subsequent same-hospital ED visits and hospital admissions. The occurrence of any subsequent ED visits or hospital admissions and the cost of subsequent hospital care were compared by free clinic referral status after inverse probability of treatment weighting.ResultsOverall, 330 (5.5%) of uninsured patients were referred to the free clinic. Compared with patients referred to the free clinic, patients not referred had greater odds of any subsequent ED visits or hospital admissions within 90 days (odds ratio, 1.8; 95% confidence interval: 1.7-2.0). For patients with any subsequent ED visits or hospital admissions, the mean cost of care for those who were not referred to the free clinic was 2.3 times higher (95% confidence interval: 2.0-2.7) compared to referred patients.ConclusionAn academic medical center-free clinic partnership for follow-up care after discharge from the ED or hospital admission is a promising approach for improving access to care for uninsured patients.     

Can continuity of primary care decrease emergency care use? A nested case-control study

BackgroundNational Health Service emergency departments have been under considerable pressure. Many patients presenting to emergency departments could be managed in primary care, suggesting that aspects of general practice might be associated with unplanned hospital admission. Recently a government scheme introduced the concept of a named GP (general practitioner) responsible for the care of patients aged 75 and older to reduce unplanned hospital admission. We aimed to investigate whether better continuity of care is associated with lower risk of emergency hospital admission.MethodsWe used records from 10 000 patients aged 65 years and over randomly selected from the Clinical Practice Research Datalink, linked with Hospital Episode Statistics. Using a nested-case control approach, we identified 769 patients with an emergency hospital admission between April 1, 2012, and March 31, 2014, and at least two GP consultations in the previous 2 years, of which the last was within 30 days before hospital admission. 2123 controls were matched on age group, last consultation within the same time-period as the case, and GP practice to account for practice composition, deprivation level, and services such as out-of-hours. For both cases and controls we calculated two longitudinal measures of continuity of care—namely, Bice and Boxerman's index, which quantifies the extent to which the patient saw the same GP, and proportion of times seen by an index GP (ie, last GP seen before admission). Conditional logistic regression models were applied to estimate the odds ratio (OR) associated with continuity of care, adjusting for sex, number of consultations, previous hospital admission, and a range of comorbidities.FindingsBoth the Bice and Boxerman and the appointed index GP measures showed a graded inverse association between lower continuity of care and higher risk of emergency hospital admission (OR for those experiencing the least continuity of care 2·1 [95% CI 1·3–3·2] and 2·3 [1·6–2·9], respectively, compared with those who always saw the same GP).InterpretationBetter continuity of care might reduce emergency hospital admission. More research is needed to understand this association including distinguishing between GP-referred emergency hospital admissions and admissions through the emergency department. Such an analysis requires a bigger data set.FundingNational Institute for Health Research School of Primary Care Research grant (round 9, project number 246).     

Risk factors for hospitalizations and readmissions among individuals with sickle cell disease: results of a U.S. survey study

Objective: Hospital admissions are significant events in the care of individuals with sickle cell disease (SCD) due to associated costs and potential for quality of life compromise.

Methods: This cross-sectional cohort study evaluated risk factors for admissions and readmissions between October 2014 and March 2016 in adults with SCD (n?=?201) and caregivers of children with SCD (n?=?330) at six centres across the U.S. Survey items assessed social determinants of health (e.g. educational attainment, difficulty paying bills), depressive symptoms, social support, health literacy, spirituality, missed clinic appointments, and outcomes hospital admissions and 30-day readmissions in the previous year.

Results: A majority of adults (64%) and almost half of children (reported by caregivers: 43%) were admitted, and fewer readmitted (adults: 28%; children: 9%). The most common reason for hospitalization was uncontrolled pain (admission: adults: 84%, children: 69%; readmissions: adults: 83%, children: 69%). Children were less likely to have admissions/readmissions than adults (Admissions: OR: 0.35, 95% CI: [0.23,0.52]); Readmissions: 0.23 [0.13,0.41]). For all participants, missing appointments were associated with admissions (1.66 [1.07, 2.58]) and readmissions (2.68 [1.28, 6.29]), as were depressive symptoms (admissions: 1.36 [1.16,1.59]; readmissions: 1.24 [1.04, 1.49]). In adults, difficulty paying bills was associated with more admissions, (3.11 [1.47,6.62]) readmissions (3.7 [1.76,7.79]), and higher spirituality was associated with fewer readmissions (0.39 [0.18,0.81]).

Discussion: Missing appointments was significantly associated with admissions and readmissions. Findings confirm that age, mental health, financial insecurity, spirituality, and clinic attendance are all modifiable factors that are associated with admissions and readmissions; addressing them could reduce hospitalizations.     

Worrisome trends of ST-elevation myocardial infarction during the Covid-19 pandemic: Data from Portuguese centers

IntroductionDuring the Covid-19 pandemic there has been a general belief that hospital admissions for non-infectious causes, especially cardiovascular diseases, have fallen.ObjectivesTo assess the impact of the pandemic on admissions for ST-elevation myocardial infarction (STEMI) during the first pandemic wave.MethodsWe performed a multicenter retrospective analysis of consecutive patients presenting with STEMI in two Portuguese hospital centers in two sequential periods – P1 (March 1 to April 30) and P2 (May 1 to June 30). Patient's clinical data and hospital outcomes were compared between the years 2017 to 2019 and 2020 for both periods.ResultsDuring P1 in 2020, a reduction in the number of STEMI patients was observed in comparison with previous years (26.0±4.2 vs. 16.5±4.9 cases per month; p=0.033), as well as an increase in the number of mechanical complications (0.0% vs. 3.0%; p=0.029). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs. 9.1%; p=0.033). An overall trend for longer delays in key timings of STEMI care bundles was noted. Mortality was higher during P1 compared to previous years (1.9% vs. 12.1%; p=0.005).ConclusionsDuring the first Covid-19 wave fewer patients presented with STEMI at the catheterization laboratory for percutaneous coronary intervention. These patients presented more mechanical complications and higher mortality.     

Alcohol misuse and injury outcomes in young people: a cohort analysis of linked primary and secondary data in England

BackgroundThe burden of disease attributed to alcohol consumption is a global problem. Alcohol misuse is thought to be a risk factor for injury in young people, though few studies have described this association in detail. This study aimed to assess the risk of hospital admission for injury in young people with a history of alcohol misuse.MethodsWe conducted a cohort study of young people aged 10–24 years registered at a Clinical Practice Research Datalink general practice between Jan 1, 1998, and Dec 31, 2013, with linked Hospital Episode Statistics data. Exposed individuals had an alcohol-specific admission to hospital between the ages of 10 and 24 years, as defined by the International Classification of Diseases, 10th revision. Unexposed individuals had no alcohol-specific admission, and were frequency matched by age (plus or minus 5 years) and general practice (ratio 10 to 1). The incidence rate (events per person-year) of first injury-related admission to hospital was calculated and the mechanisms described. Hazard ratios (HR) adjusted for age, sex, deprivation, and region were estimated by Cox regression, with an interaction term included between exposure and time.FindingsThe cohort comprised 11 042 exposed and 110 656 unexposed individuals. Exposed individuals had longer median follow-up time than unexposed individuals (2·17 years [IQR 0·82–4·44] vs 1·20 [0·38–3·09]), and were more likely to be from the most deprived socioeconomic quintile (3274 [29·7%] exposed vs 26 990 [24·3%] unexposed) and be male (56·8% exposed vs 47·3% unexposed). 4944 injury-related admissions occurred (2092 exposed, 2852 unexposed), with injury rates higher in those with than in those without a previous alcohol admission (73·92 per 1000 person-years, 95% CI 70·82–77·16 vs 12·36, 11·91–12·81). Individuals with a previous alcohol-specific admission were 5·28 times more likely to have an injury admission than those without at 1 year (HR 5·28, 95% CI 4·97–5·60), with the interaction term (0·65, 95% CI 0·62–0·67) indicating that injury risk significantly depreciated after alcohol admission. The most common injury mechanism was poisoning in exposed individuals and falls in unexposed individuals.InterpretationThis is the largest study, to our knowledge, demonstrating that alcohol-specific admissions to hospital are associated with subsequent admission for injury in young people, with risk of injury greatest after the alcohol admission and reducing over time. This finding indicates a need for early intervention during admissions and after discharge, providing information and referral (eg, specialist alcohol or mental health services), and developing effective interventions to reduce subsequent risk of injury.FundingNational Institute for Health Research (NIHR) School for Primary Care Research.