A qualitative study to inform the development of interventions to reduce primary care sensitive hospital admissions

Admissions to hospital are an increasing source of pressure on the NHS.  Unplanned admissions to hospital represent 37% of admissions in the UK. Unplanned admissions are expensive; create uncertainty for those planning and delivering services and are distressing for patients and carers. 

Primary care sensitive admissions (PCSAs) are those that ideally would have been prevented by care outside hospital. PCSAs constitute about 34% of unplanned hospital admissions. There is considerable variation in rates of unplanned admission across hospitals and GP practices, even after controlling for socio-demographic variables, and also considerable variance between individual GPs.  The majority of this variance is unexplained.  There is little available evidence about how clinicians make decisions to admit patients.   

Aims

This research aims to answer the following questions:

1. What is the impact of primary care clinician discretion and decision-making, practice factors and primary care commissioning culture on PCSAs?

2. What views and preferences do patients have about unplanned admission for PCSAs? 

3. What are decision makers views regarding useful and acceptable interventions that might avert potentially avoidable PCSAs?

There is little research evidence to inform interventions to reduce PCSAs. There have been no RCTs of interventions at the GP or individual patient level to reduce rates of PCSAs. This research will provide information on factors associated with admission for PCSAs, incentives and barriers to reduce PCSAs at the time of admission and the acceptability of interventions. 

Methods

Qualitative study of primary care staff, community matrons, ambulance trust staff, social care staff, admitting secondary care staff and patients. Semi-structured interviews and focus groups with purposive samples of: practice staff to include GPs, practice and community nurses, practice managers, patients, out-of-hours clinicans, community matrons, ambulance trust staff, PCT staff, social services staff and secondary care clinicians.  Facilitated discussion of topic guide developed from the literature and pilot interviews.  Discussion will focus on data on admissions and vignettes of patients referred and admitted/not admitted.

All interviews and group discussions will be recorded and transcribed.  Data will be analysed using a Framework approach

Potential Impact

This study will provide information about the clinical, social and health service decisions that are made when assessing a patient who may need an unplanned admission to hospital.  The study will identify why decisions are made, what factors infuence these decisions and what alternatives may be acceptable to the various stakeholders involved. It will also explore professional's and patient's views about other interventions that could reduce avoidable admissions. The information from this study will assist clinicians and policymakers with the implementation of interventions to reduce the number of avoidable admissions, thereby benefiting patients and NHS. It will inform the development and delivery of services that are acceptable to both patients and health and social care professionals.

Publications:

Simmonds R, Shaw A, Purdy S. Factors influencing professional decision making on unplanned hospital admission: a qualitative study. British Journal of General Practice 2012; 62(604):e750-e756. http://dx.doi.org/10.3399/bjgp12X658278