1. Urban-Rural Inequalities in Potentially Preventable Hospital Admissions Carolyn Hunter-Rowe Senior Health Intelligence Analyst Department of Public Health NHS Dumfries and Galloway

2. Potentially Preventable Admissions “represent a range of conditions that result from medical problems that may be preventable with the application of public health measures or through early disease management and treatment in primary care.” [Agency for Healthcare Research and Quality, 2007]

3. Background Concept of avoidable / preventable admissions  population-based health improvement e.g. alcohol, smoking  prevention of adverse events – accidents, injuries, falls  intervention in primary care – ambulatory care sensitive conditions (ACSCs) Ambulatory care sensitive conditions  Vaccine-preventable e.g. influenza, bacterial pneumonia  Acute medical e.g. cellulitis, dehydration, gastroenteritis  Chronic conditions e.g. angina, COPD, diabetes Indicator of avoidable morbidity and the accessibility and quality of primary health care

4. Potentially Preventable Admissions by Main Diagnosis Group, NHS Scotland, 2009/10 n = 85,721

5. Context Environment / setting is a key determinant of health and wellbeing “where people live affects their health and chances of leading flourishing lives” [CSDH, 2008] Inequalities between urban-rural areas in UK and Scotland  self-reported health [Levin 2003, Riva et al. 2009]  cancer [Campbell et al. 2001]  ischaemic heart disease [Levin & Leyland 2006] International literature – mixed evidence re PPAs, generally positive association with rurality

6. Study Aims 1.To determine whether the prevalence of hospital admissions for potentially preventable conditions is associated with urban or rural area of residence in Dumfries and Galloway. 2.To determine the extent to which any differences are explained by deprivation after controlling for differences in the study populations.

7. Methodology Data Source - SMR01, Apr 2005 to Mar 2010 Primary outcome - rate of admission Standardised Admission Ratios (SARs) Negative binomial regression Independent variables: age, sex, socio- economic status, co-morbidities, urban-rural classification, distance to hospital, drive to GP Incidence Rate Ratios (IRRs) - relative risk of admission

8. Setting

9. Study cohort 193 datazones: 102 urban, 91 rural 18,675 hospital admissions over 5 year period 48% male, 52% female Mean age 47.0 years (M) and 49.0 years (F) 13.7% resided in most deprived quintile, 5.5% least deprived (SIMD09) Area of residence 59.5% urban, 40.5% rural

10. Standardised Admission Ratios SAR: Urban 112.1, Rural 87.3 (p<0.0001).

11. Correlation between Standardised Admission Ratios and SIMD Score

12. Predictors of Preventable Admissions Variable (reference)Incidence Rate Ratio (95% CI) Model 1: AgeModel 2: Age, SIMD Model 3: Age, SIMD, Distance Urban1.00 Rural0.77 (0.71, 0.84)0.80 (0.75, 0.86)0.85 (0.79, 0.92) Age 0-151.00 16-440.61 (0.57, 0.65)0.61 (0.58, 0.65) 45-640.58 (0.54, 0.62)0.59 (0.55, 0.63)0.59 (0.56, 0.63) 65-741.11 (1.03, 1.20)1.13 (1.05, 1.22)1.14 (1.05, 1.23) 75+2.17 (2.01, 2.36)2.23 (2.06, 2.42)2.25 (2.08, 2.43) SIMD09 1 - most1.00 20.79 (0.71, 0.88)0.80 (0.71, 0.89) 30.72 (0.65, 0.80)0.72 (0.64, 0.80) 40.62 (0.56, 0.69)0.61 (0.54, 0.68) 5 - least0.54 (0.45, 0.64)0.52 (0.45, 0.62) results significant at p=0.05 highlighted in bold

13. Adjusted admission rates by age group and urban-rural category

14. Adjusted admission rates by area-based deprivation and urban-rural category

15. Main Findings Inequalities in potentially preventable admissions within both urban and rural areas Adjusted admission rates 15% lower in rural areas compared to urban areas Risk of admission higher in the most deprived quintile compared to the least deprived Significant positive association with deprivation in both urban and rural areas Higher admission rates for the elderly population in rural areas

16. Conclusions Large proportion of variation in potentially preventable admissions accounted for by socio- demographic factors and accessibility to services Evidence of inequalities in potentially preventable admissions should be used to inform healthcare strategy and service development. Importance of understanding geographic inequalities within local context to ensure service provision meets health needs of the population Larger study could explore intra-rural variations that were outwith the scope of this research

17. Acknowledgements University of Manchester Dr Isla Gemmell Abdelouahid Tajar NHS Dumfries and Galloway Dr Andrew Carnon Elisabeth Smart