Potentially preventable emergency admissions

We use Hospital Episode Statistics data to look at potentially preventable emergency admissions to hospital.

Qualitywatch

Indicator

Last updated: 17/08/2023

Background

Emergency admissions, where patients are admitted to hospital urgently and unexpectedly (i.e. the admission is unplanned), are unpleasant experiences for patients and costly for a healthcare provider. Many hospital admissions related to long-term conditions could potentially be avoided with timely and effective community care. These conditions are known as ambulatory care sensitive (ACS) and urgent care sensitive (USC) conditions. Here we look at emergency admission rates for these conditions in England, as well as emergency admission rates internationally for three common chronic conditions: chronic obstructive pulmonary disease (COPD), asthma and diabetes.

Key definitions:

Ambulatory care sensitive (ACS) conditions are conditions where effective community care and person-centred care can help prevent the need for hospital admission.

Urgent care sensitive (UCS) conditions are acute exacerbations of urgent conditions that a care system should treat and manage close to home and without the need for hospital admission in as many cases as possible. Although some of these admissions are necessary, a high rate may indicate avoidable admissions.


Emergency admissions that could potentially be avoided

Between 2008/09 and 2019/20, the number of emergency admissions for ACS conditions and urgent care sensitive conditions increased by 18% and 20% respectively (data not shown). However, rates of emergency admissions for these conditions remained relatively stable over the same time period. This is arguably a good result given that the total number of emergency admissions to hospital has risen over time, increasing by 25% between 2011/12 and 2019/20.

Data for 2020/21 shows a decrease in emergency admissions for ACS conditions and urgent care sensitive conditions. Compared with 2019/20, the number of emergency admissions for ACS conditions fell by 22% and emergency admissions for urgent care sensitive conditions fell by 16% (data not shown). Since this came alongside a 16% fall in total emergency admissions during the coronavirus (Covid-19) pandemic, it is difficult to draw conclusions about the change in quality of care.

In 2021/22, emergency admissions increased, inching closer to the volumes recorded pre-pandemic. Eight in every 1,000 people in England were admitted to hospital in an emergency with an ACS condition in 2021/22, and 22 in every 1,000 people were admitted with an urgent care sensitive condition.


Emergency admissions for ambulatory care sensitive conditions

This chart shows the percentage change in emergency admissions for specific ambulatory care conditions compared with the equivalent month in 2018/19 (April 2018 to March 2019). For example, there were 4% more emergency admissions for heart failure in January 2020 than in January 2019. 

Between April 2019 and February 2020, there was a moderate change in admissions for different conditions compared with 2018/19, ranging from a 32% increase in admissions for hypertension (high blood pressure) in July 2019 to a 13% decrease in admissions for chronic heart disease in December 2019. 

Between February 2020 and April 2020, the initial months of the Covid-19 pandemic, there was a 52% drop in emergency admissions for all listed ambulatory care sensitive conditions and a 36% drop in total emergency admissions (not shown). Since then, the change in emergency admissions for different ACS conditions from 2018/19 has varied to a much greater extent than before the pandemic. Conditions such as asthma and COPD have seen a marked decrease in emergency admissions, whereas emergency admissions related to hypertension and blood anaemia have increased. In March 2023, the biggest changes in emergency admissions were for hypertension (118% increase) and COPD (25% decrease). 

For more information about ambulatory care sensitive (ACS) conditions, please see the About this data section of this page. 


Emergency admissions for urgent care sensitive conditions

Overall, rates of emergency admissions are highest for falls, non-specific chest pain, and non-specific abdominal pain, but individual urgent care sensitive conditions have exhibited different trends over time. Between 2008/09 and 2019/20, the rate of emergency admissions increased for falls, cellulitis, urinary tract infections, COPD and acute mental health crisis, but decreased for angina and non-specific chest pain. The rate of emergency admissions remained relatively steady for the other urgent care sensitive conditions. Note that the drop in emergency admissions for falls in 2012/13 related to changes in clinical coding, and the decrease in urinary tract infection admissions in 2017/18 was linked to improved coding of sepsis.

In 2020/21, the emergency admission rate fell by varying degrees for all conditions except deep vein thrombosis and angina, where rates remained constant. The largest decrease was for COPD, which fell from 23 emergency admissions per 1,000 people in 2019/20 to 13 per 1,000 people in 2020/21. In 2021/22, the rate increased for most conditions where it had fallen due to the pandemic. Emergency admissions related to falls had the highest rate (44 per 1,000 people), followed by non-specific chest pain (41 per 1,000 people) and non-specific abdominal pain (37 per 1,000 people) in 2021/22. 

For more information about urgent care sensitive (UCS) conditions, please see the About this data section.


International comparison of hospital admissions for COPD

International comparison of hospital admissions for asthma

COPD and asthma are common lung diseases that can make breathing difficult. Overall, hospital admission rates are higher for COPD than for asthma or diabetes-related conditions. In the UK, the age-sex standardised COPD hospital admission rate is higher than the average of all the reported Organisation for Economic Co-operation and Development (OECD) countries, and the hospital admission rate for asthma is the highest of all the comparator countries.

Between 2006 and 2019, the hospital admission rates for COPD and asthma in the UK have not varied significantly. However, the onset of the Covid-19 pandemic in 2020 led to fewer emergency admissions pertaining to these conditions. There was a 32% reduction for COPD, from 239 admissions per 100,000 population in 2019 to 163 admissions per 100,000 population in 2021. For asthma, the rate dropped by 37% from 75 admissions per 100,000 population in 2019 to 47 admissions per 100,000 population in 2021. The reason for this decrease in admissions is complex, and may be behavioural (stay at home messaging and fear of acquiring the virus resulting in reduced help-seeking behaviour) and/or environmental (reduced respiratory virus transmission and lesser air pollution due to lockdown measures). 

Time trends for the other countries presented here vary considerably. For example, there has been a continuous decrease in hospital admission rates for COPD and asthma in Italy and Finland, but up until 2020, admission rates for these conditions in Germany and the Netherlands have shown an increase.

The Taskforce for Lung Health’s five-year plan states that there has been little or no improvement in outcomes for people with lung disease in the UK for more than ten years, while other countries have made significant progress. The report highlights that avoidable hospital admissions can be prevented by enabling patients to practice better self-management and implement evidence-based interventions for COPD and asthma, such as pulmonary rehabilitation and new technology, including smart inhalers. 


International comparison of hospital admissions for diabetes

Diabetes is a common chronic condition for which inadequate management can lead to a range of short-term (e.g. diabetic coma) and long-term (e.g. cardiovascular disease, retinopathy and kidney disease) complications. The hospital admission rate for diabetes in the UK has remained relatively constant over time, and in 2021, 80 admissions per 100,000 population were recorded.

Only Italy, Spain, Portugal and the Netherlands have lower hospital admission rates for diabetes than the UK, with Italy having the lowest rate in 2021 (31 admissions per 100,000 population). Despite having lower hospital admissions, the estimated prevalence of diabetes in 2019 was higher in Italy (5%), Spain (6.9%), Portugal (9.8%) and the Netherlands (5.4%) than in the UK (3.9%). This suggests that although there are fewer diabetic patients in the UK, a higher proportion of them have had an emergency hospital admission for their condition relative to the comparator countries. 

Whilst hospital admission rates have been stable in the UK, many adults and children still do not receive the recommended care processes for diabetes. There are also large variations across Europe in the quality of care provided and diabetes outcomes (see SWEET project).

Individuals with diabetes are at risk of having a lower extremity (below the knee) amputation if high blood sugar levels leave their blood vessels damaged and disrupt blood flow to the legs and feet, resulting in ulcers and foot infections. Even a minor amputation can result in losing a whole foot and seriously impede a person’s basic functionality and quality of life. 

Like most other countries, the UK has maintained a relatively stable rate of admissions for lower extremity amputations, averaging 3 admissions per 100,000 population up until 2020. In 2021, it increased to 7 per 100,000 population.

Many amputations may be prevented with targeted preventative services and fast access to high-quality foot care. The NHS Long Term Plan announced continued support to local health systems to provide access to multidisciplinary foot care teams for patients who need secondary care support.

It is important to be mindful of the differences in coding practices (e.g. major/minor amputations) that are likely to have an impact on the observed differences between countries. OECD and country experts are working to further improve the quality of the diabetes data.


 

About this data

These indicators use data from Hospital Episode Statistics (HES) and the Organisation for Economic Co-operation and Development (OECD). The HES indicators were calculated according to NHS Digital's CCG Outcomes Indicatorspecifications. The defined list of ambulatory care sensitive conditions and urgent care sensitive conditions are as follows:

·       Ambulatory care sensitive conditions: chronic viral hepatitis B, diabetes mellitus, sideropenic dysphagia, anaemia, dementia, epilepsy, hypertension, angina pectoris, chronic ischaemic heart disease, heart failure, atrial fibrillation, pulmonary oedema, bronchitis, emphysema, chronic obstructive pulmonary disease, asthma, bronchiectasis.

·       Urgent care sensitive conditions: COPD, acute mental health crisis, non-specific chest pain, falls (aged 74 and over), non-specific abdominal pain, deep vein thrombosis, cellulitis, pyrexial child (aged 6 years and under), blocked tubes, catheters and feeding tubes, hypoglycaemia, urinary tract infection, angina, epileptic fit, minor head injuries.

This work uses data provided by patients and collected by the NHS as part of their care and support. Read more on our website.

Office for National Statistics population estimates were used to calculate rates of emergency admissions. 

International indicators:

Definitions and comparability for the international indicators are taken directly from the OECD report Health at a Glance 2021: OECD indicators. Detailed information about the definitions and the source and methods for each country can be found here.

The asthma and COPD indicators are defined as the number of hospital admissions with a primary diagnosis of asthma or COPD among people aged 15 years and over per 100,000 population. Rates are age-sex standardised to the 2010 OECD population aged 15 and over. Admissions resulting from a transfer from another hospital and where the patient dies during the admission are excluded from the calculation as these admissions are considered unlikely to be avoidable.

Diabetes avoidable admission is based on the sum of three indicators: admissions for short-term and long-term complications and for uncontrolled diabetes without complications. The indicator is defined as the number of hospital admissions with a primary diagnosis of diabetes among people aged 15 years and over per 100,000 population. Rates were directly age-sex standardised to the 2010 OECD population.

Differences in data definition and coding practices between countries may affect the comparability of data. For example, coding of diabetes as a principal diagnosis versus a secondary diagnosis varies across countries. This is more pronounced for diabetes than other conditions, given that in many cases admission is for the secondary complications of diabetes rather than diabetes itself. 

One of the main problems with these indicators is that they only look at hospital admissions and do not consider any differences in disease prevalence. For example, regarding diabetes, it is not clear whether lower admission rates are due to a lower prevalence of diabetes in the population or better management of people with diabetes.

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