What factors are associated with ambulance conveyance to hospital in patients with diabetes or diabetes-related emergencies in care homes? Cross sectional database study

Problem

Diabetes, affects over 1 in 5 nursing or residential care home residents which may lead to diabetes-related or other emergencies resulting in ambulance call-outs and hospitalisation. We aimed to investigate ambulance call-outs to care home residents with diabetes-related emergencies, to determine clinical and demographic predictors of ambulance conveyance to hospital, and to estimate costs of ambulance attendance and transportation.

Approach

We employed a cross-sectional design using ambulance care record and dispatch data from a regional ambulance trust together with care home data from the Care Quality Commission (CQC), for people calling an ambulance in the East Midlands over six years, from January 2012 to December 2017. We included data on place of residence (care home vs non-care home community dwelling), care home characteristics (CQC quality rating, nursing vs residential status, Index of Multiple Deprivation), call day and timing, together with patient characteristics (age, sex), physiological status, treatments received, outcome (conveyance) and costs. We constructed multivariable logistic models fitting factors potentially associated with conveyance to hospital. We fitted a predictive statistical model to the costs from a health service perspective for ambulance calls and associated hospital care costs, for care homes resident where an ambulance was called for a diabetes-related emergency.

Findings

Overall 219722 (6.7% of 3.3 million) attendances were to care home residents of which 12080 (5.5%) were for diabetes-related emergencies. Of 3152 care home patients categorised as having a ‘diabetic problem’ 1,957 (62.1%) were conveyed to hospital. Despite access to trained staff in care homes, this was not significantly different to the rate for community dwelling people not in care homes, taking into account other factors. Factors which were statistically significantly associated with conveyance included reduced consciousness level (odds ratio [OR] for mean Glasgow Coma Scale 0.91, 95% confidence interval [CI] 0.87-0.95), elevated heart (OR 1.01, 95% CI 1.01-1.02) or respiratory rate (OR 1.08, 95% CI 1.06-1.10), no treatment for hypoglycaemia (OR 0.54, 95% CI 0.34-0.86) or additional co-morbid medical (but not psychiatric) problems. Cost to EMAS was significantly lower when a patient was conveyed, by some £18 (95% CI £11.94-£24.12), but this would not outweigh downstream NHS costs arising from hospital care. For a simulation in which all trusts’ mean NHS reference costs were used, conveyance was no longer significant in the cost model.

Consequences

Conveyance to hospital was as common for care home patients with diabetes-related emergencies as for non-care home community dwelling patients, and more likely when conscious level was impaired, heart or respiratory rate abnormal or when treatment for hypoglycaemia was not given by ambulance clinicians. The study has implications for better training of staff, access to guidelines and primary care, and support to improve monitoring treatment and emergency care for these individuals.