Emergency admissions, where patients are admitted to hospital urgently and unexpectedly (ie, the admission is unplanned), are both costly and frequently unpleasant experiences for patients. 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 conditions. Here we look at emergency admission rates for these conditions in England, as well as three common chronic conditions - chronic obstructive pulmonary disease (COPD), asthma and diabetes - internationally.
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 conditions are acute exacerbations of urgent conditions which 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.
Between 2008/09 and 2017/18, the number of emergency admissions for ACS conditions and urgent care sensitive conditions increased by 9% and 11%, 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 increased by 22% since 2008. Nevertheless, almost nine in every 1,000 people in England were admitted to hospital in an emergency with an ACS condition in 2017/18, and 23 in every 1,000 people were admitted with an urgent care sensitive condition. This is surprisingly high given that these are potentially preventable causes of emergency admission.
Between 2008/09 and 2017/18, the percentage change in rates of emergency admissions to hospital for ACS and urgent care sensitive conditions varied considerably by age group. In particular, rates of emergency admissions for these conditions in people aged 0 to 15 and 65 to 74 have improved, but for people aged 25 to 34 and 85 or over they have worsened.
Individual urgent care sensitive conditions exhibited different trends over time. Between 2008/09 and 2017/18, the rate of emergency admissions increased for falls, cellulitis, urinary tract infections and COPD, but decreased for angina and non-specific chest pain. The rate of emergency admissions remained relatively steady for the other urgent care sensitive conditions.
The drop in emergency admissions for falls in 2012/13 relates to changes in clinical coding, and the decrease in urinary tract infection admissions in 2017/18 is linked to improved coding of sepsis. Compared to the other urgent care sensitive conditions, rates of emergency admissions are highest for non-specific chest pain, non-specific abdominal pain and falls.
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 relatively high compared to other OECD countries, and the hospital admission rate for asthma is the highest of all the comparator countries apart from the United States.
However, there has been a slight reduction in hospital admission rates for COPD and asthma in the UK over time. For COPD, there was an 8% reduction from 250.8 admissions per 100,000 population in 2006 to 231.8 admissions per 100,000 population in 2015. For asthma, the rate dropped by 10% from 79.3 admissions per 100,000 population in 2006 to 71 admissions per 100,000 population in 2015. This decrease may reflect some improvement in the quality of care provided for these conditions.
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 admission rates for these conditions in Germany and the Netherlands have been increasing. Japan has the lowest hospital admission rate for COPD and Italy has the lowest rate for asthma.
While this indicator does not focus on respiratory deaths, it is worth noting that the inquiry by the All Party Parliamentary Group on Respiratory Health (2014) into respiratory deaths concluded that the quality of services and outcomes in the UK was very poor compared to other countries and that urgent action was needed. The inquiry highlighted that awareness in the population as well as among non-specialist professionals, and the effective implementation of existing, evidence-based clinical guidelines, should be prioritised in order to prevent potentially unnecessary admissions and deaths. Other reports have highlighted concern about the quality of care provided to asthma and COPD patients (Department of Health, 2012; Healthcare Quality Improvement Partnership, 2014b).
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. Between 2011 and 2015, the hospital admission rate for diabetes in the UK was stable at 72.8 admissions per 100,000 population, which is one of the lowest rates compared to other OECD countries.
Only Portugal, Italy and Spain have lower hospital admission rates for diabetes compared to the UK, with Italy having the lowest rate in 2015 (39.7 admissions per 100,000 population). Despite lower hospital admissions, the estimated prevalence of diabetes in 2015 was higher in Portugal (9.9%), Italy (5.1%) and Spain (7.7%) than in the UK (4.7%) (OECD, Health at a Glance 2017). Ideally, we would like to measure hospital admissions within the diabetes population rather than the general population. Whilst hospital admission rates have been stable in the UK, many adults, but especially children, still do not receive the recommended care for diabetes (Royal College of Paediatrics and Child Health, 2015) and there are large variations around Europe in the quality of care provided and diabetes outcomes (e.g. HbA1c control) (see SWEET project).
Looking more specifically at hospital admission rates for diabetes lower extremity amputations, these have remained stable over time in the UK, at 2.9 admissions per 100,000 population in 2015. The rate has also been stable in most other OECD countries. The UK has a good level of performance relative to other countries. However, Finland outperformed the UK in 2015 with only 2.8 amputations per 100,000 population. Evidence from England suggests that many of the amputations could still be prevented with targeted preventative services and fast access to high-quality foot care (Kerr, 2012). Also, multidisciplinary diabetic foot care teams improve outcomes and reduce costs to the NHS (Kerr, 2012).
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 Indicator specifications. 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.
Definitions and comparability for the international indicators are taken directly from the OECD report Health at a Glance 2017: 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 look only at hospital admissions and do not take account of differences in disease prevalence. For example, with regard to 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.