Implementation of emergency admission risk stratification: A cross sectional survey of 171 UK health boards and CCGs

Problem

New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. To help prevent admissions through improved targeting, emergency admission risk prediction (EARP) tools have been developed. They use routinely collected health and demographic data to stratify patients according to their risk of emergency admission in a given timeframe – typically 12 months. Despite limited evidence such tools have been widely advocated in international primary care policy and contracts. This is especially true of the UK, where an unplanned admissions enhanced service in England alone has allocated £480 million to support proactive primary care for those at high risk of emergency admission. It is however, unclear how many general practices have access to a risk tool, and which factors influence their adoption and use.

Approach

We undertook the first UK wide study of EARP tool use. We invited all 235 UK organisations responsible for primary care commissioning (CCGs and health boards) to participate in a cross-sectional survey, and followed up a sample for telephone interviews. We administered the survey using the SurveyMonkey platform, and invited responses between November 2016 and June 2016. The survey explored:

• risk tool availability

• factors that influence adoption

• how the tools are used in general practice (and wider)

• whether the introduction of tools has prompted service changes

The follow up surveys, conducted in late 2016, further explored these issues and future plans for risk stratification tools.

Findings

171 organisations responded to the survey (74%) – 153 in England, 9 in Scotland and all 7 and 5 in Wales and Northern Ireland. A sample of 20 completed telephone interviews.

We found that EARP tools had been implemented in 87% of CCG and health board areas – and in the majority of general practices within. There was variation across the four nations and within England. 28 separate tools were in use. Factors encouraging the uptake of tools at general practice level include practice manager engagement, promotion by health board/CCG and the role of clinical leaders. Factors inhibiting uptake included workload of practice and community staff, information governance and issues with integration with clinical systems. 52% of areas confirmed they had made or were planning changes to local services due to the use of risk tools. 18% were using risk tools as part of service evaluations.

Consequences

EARP tools are widespread, but not universal across health board and CCGs of the UK. While development and uptake has been prompted by national contracts, other factors are important also. Many areas plan to encourage general practice use of EARP tools following the end of enhanced service incentives – but there is wide variation in these plans and most lack supportive evidence. Effectiveness studies are needed to inform and support decision makers.