1. How can we use geographic variation in unplanned admissions to improve efficiency? John Busby CLAHRC West

2. Motivation SchizophreniaHip Fracture

3. CLAHRC West Outline Background Magnitude of geographic variation Causes of geographic variation Benchmarking

4. CLAHRC West What are ACSCs? Improved community care can often prevent admission –Prevent disease onset –Control acute episode –Manage chronic condition Definition varies One in six unplanned admissions Increasing policy importance

5. CLAHRC West What are ACSCs? Diabetes COPD Asthma CHF ENT infection Pyelonephritis Influenza Alcohol-related diseases Constipation Migraine Schizophrenia Stroke Ruptured appendix Hip fracture

6. CLAHRC West Context Moderate NHS budget growth Unplanned admissions –67% bed days –£13bn annually –Increasing A&E Pressures Policy initiatives

7. CLAHRC West How does variation help? Several drivers of admission rates –Unmodifiable –Spurious –Modifiable Can help identify –Variable pathways –Admission avoidance interventions

8. Magnitude of Variation

9. CLAHRC West Methods Hospital Episode Statistics from 2011/12 Variation between primary care trusts Random-effect Poisson models Adjusted for potential confounders –Age –Sex –Deprivation Investigated difference in short-stay admissions –Comorbidities –Lifestyle

10. CLAHRC West Methods

11. CLAHRC West Results, descriptives 1.8 million ACSC admissions Patients generally –Older –Comorbidities –High deprivation –Through A&E Substantial variation in demographics between conditions

12. CLAHRC West Results, geographic variation UR = 1.26 (95% CI: 1.23, 1.30) for all ACSCs combined

13. CLAHRC West Results, geographic variation

14. CLAHRC West Results, geographic variation

15. CLAHRC West Results, geographic variation Short-stay admissions often more variable

16. CLAHRC West Results, geographic variation

17. CLAHRC West Why do variations exist? Substantial variation in healthcare delivery –Primary care –Community care –Secondary care Some more important for certain ACSCs or for short-stay admissions Other condition specific factors at play –e.g. PVD, dental conditions, mental health

18. CLAHRC West Variations in priority setting Current research priority setting system suboptimal –Relies on stakeholders to identify important practice variability Routine examination of geographic variations could identify important research questions

19. CLAHRC West Variations in priority setting Up to 2.8 million bed days could be saved through reductions in admission rates Commissioners should use variations data when identifying areas for improvement (e.g. benchmarking) Mental health and short-stay admissions could offer the easiest gains

20. CLAHRC West A Few Limitations Inability to identify which admission rate is ‘correct’ Possibility of confounding Reliant on consistent coding

21. Causes of Variation

22. CLAHRC West Methods Negative binomial regression Population, practice and hospital factors Linked to publically-available datasets Adjusted for potential confounders Rate in high (90 th centile) vs low (10 th centile)

23. CLAHRC West Results, geographic variation Substantial variation in healthcare delivery

24. CLAHRC West Results, geographic variation … even within BNSSG

25. CLAHRC West Results, geographic variation Several factors strongly associated with unplanned admission rates Non linear effect for A&E proximity Small associations for some characteristics

26. CLAHRC West Results, geographic variation Importance differs by ACSCs

27. CLAHRC West Results, geographic variation

28. CLAHRC West Managing performance Take ‘unmodifiable’ factors is to account

29. CLAHRC West Designing interventions Depends on cause, multifaceted interventions required –Improve continuity (e.g. patient trade-off, more GPs, improved handovers) –Monitor and reduce bed numbers? –Senior decision making in A&E –New emergency payment models Should GP access by emphasised? What role should the QOF play?

30. CLAHRC West Other Evidence RCTs of interventions are rare –No evidence for medicine reviews and ‘hospital at home’ –Case management and specialist clinics conflicting –Individualised discharge planning can reduce readmissions Paramedic education can reduce A&E conveyance and admissions

31. Benchmarking

32. CLAHRC West Definition Comparison to attain best practice National and local relevance Potential pitfalls –Are differences appropriate? –Why do they exist? Has been used to achieve savings within NHS (see CfV case studies)

33. CLAHRC West Case-mix adjustment ‘We understand the population difference, we understand the landscape, and we can interpret based on that’ ‘It leads to increased complexity’ ‘I don’t think most NHS operational managers understand numbers’

34. CLAHRC West Case-mix adjustment Adjustment can change conclusions

35. CLAHRC West CLAHRC Benchmarking Seven partner CCGs Large number of inpatient and outpatient procedures Investigation of causes (‘deep dives’, interviews) Assessment of appropriateness

36. CLAHRC West Acknowledgments The research is supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West (CLAHRC West) at University Hospitals Bristol NHS Foundation Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Email: john.busby@bristol.ac.ukjohn.busby@bristol.ac.uk Twitter: @johnbusby2491, @CLAHRC_West@johnbusby2491@CLAHRC_West Website: clahrc-west.nihr.ac.ukclahrc-west.nihr.ac.uk