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OBJECTIVE: To determine the subsequent pattern of emergency admissions in older people with a history of frequent emergency admissions. Design Analysis of routine admissions data from NHS hospitals using hospital episode statistics (HES) in England. Subjects Individual patients aged ≥ 65, ≥ 75, and ≥ 85 who had at least two emergency admissions in 1997-8. MAIN OUTCOME MEASURES: Emergency admissions and bed use in this "high risk" cohort of patients were counted for the next five years and compared with the general population of the same age. No account was taken of mortality as the analysis was designed to estimate the future use of beds in this high risk cohort. RESULTS: Over four to five years, admission rates and bed use in the high risk cohorts fell to the mean rate for older people. Although patients ≥ 65 with two or more such admissions were responsible for 38% of admissions in the index year, they were responsible for fewer than 10% of admissions in the following year and just over 3% five years later. CONCLUSION: Patients with multiple emergency admissions are often identified as a high risk group for subsequent admission and substantial claims are made for interventions designed to avoid emergency admission in such patients. Simply monitoring admission rates cannot assess interventions designed to reduce admission among frail older people as rates fall without any intervention. Comparison with a matched control group is necessary. Wider benefits than reduced admissions should be considered when introducing intensive case management of older people.

ObjectiveTo estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).DesignControlled longitudinal study. SettingEnglish National Health Service between 1998/99 and 2010/11.ParticipantsPopulations registered with each of 6975 family practices in England.Main outcome measuresYear specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.ResultsIncentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11.ConclusionsThe introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

OBJECTIVE:s To develop a formula for allocating resources for commissioning hospital care to all general practices in England based on the health needs of the people registered in each practice Design Multivariate prospective statistical models were developed in which routinely collected electronic information from 2005-6 and 2006-7 on individuals and the areas in which they lived was used to predict their costs of hospital care in the next year, 2007-8. Data on individuals included all diagnoses recorded at any inpatient admission. Models were developed on a random sample of 5 million people and validated on a second random sample of 5 million people and a third sample of 5 million people drawn from a random sample of practices. Setting All general practices in England as of 1 April 2007. All NHS inpatient admissions and outpatient attendances for individuals registered with a general practice on that date. Subjects All individuals registered with a general practice in England at 1 April 2007. MAIN OUTCOME MEASURES: Power of the statistical models to predict the costs of the individual patient or each practice’s registered population for 2007-8 tested with a range of metrics (R2reported here). Comparisons of predicted costs in 2007-8 with actual costs incurred in the same year were calculated by individual and by practice. RESULTS: Models including person level information (age, sex, and ICD-10 codes diagnostic recorded) and a range of area level information (such as socioeconomic deprivation and supply of health facilities) were most predictive of costs. After accounting for person level variables, area level variables added little explanatory power. The best models for resource allocation could predict upwards of 77% of the variation in costs at practice level, and about 12% at the person level. With these models, the predicted costs of about a third of practices would exceed or undershoot the actual costs by 10% or more. Smaller practices were more likely to be in these groups. CONCLUSIONS: A model was developed that performed well by international standards, and could be used for allocations to practices for commissioning. The best formulas, however, could predict only about 12% of the variation in next year’s costs of most inpatient and outpatient NHS care for each individual. Person-based diagnostic data significantly added to the predictive power of the models.

OBJECTIVE:s To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Design Practice level before and after analysis of hospital admissions data with control group. Setting Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. MAIN OUTCOME MEASURES: Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). RESULTS: The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval –5.7% to 38.7%), emergency bed days (increase 19.0%, –5.3% to 43.2%), and mortality (increase 34.4%, –1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged ≥65 effects on the rates of emergency admission (increase 2.5%, –2.1% to 7.0%), emergency bed days (decrease –4.9%, –10.8% to 1.0%), and mortality (increase 5.5%, –3.5% to 14.5%) were also non-significant. CONCLUSIONS: Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.