Tackling the issue of emergency
admissions
The impact of anaemia and the prospect of reducing 15,000
emergency admissions and over 8,000 bed days each year
UK/OTH/14/0227
Date of preparation: October 2014
Overview
08:30 – 08:40
Anaemia, identifying an opportunity
Liz Mills, Vifor Pharma UK
08:40 – 08:55
What does good care look like for
anaemia patients in the NHS?
Professor Ceri Phillips, Swansea University
08:55 – 09:05
Where to start? Putting
recommendations into practice
Dr James Kingsland, National Association of Primary Care
09:05 – 09:15
UK/OTH/14/0227
Date of preparation: October 2014
Discussion and closing remarks
Anaemia, identifying an
opportunity
Liz Mills, Vifor Pharma UK
UK/OTH/14/0227
Date of preparation: October 2014
Reducing preventable admissions
£500m saving
163,000 hospital
stays
447 admissions
per day
100,000 days in
hospital from
delayed
discharge
UK/OTH/14/0227
Date of preparation: October 2014
What is iron deficiency anaemia?
• Estimated that 2-5% of all adult men and postmenopausal women in UK have IDA1
• Anaemia defined as Hb level <12g/dL in women
and <13g/dL in men2
• IDA = anaemia where iron deficiency is evident by
low serum ferritin (<30μg/L)3
• In the presence of inflammation (elevated CRP)
cutoff values to indicate iron deficiency are higher
(<100μg/L)3
1. Goddard AF, et al. Gut 2011;60:1309–1316
UK/OTH/14/0227
2. WHO.
Worldwide prevelance of anaemia 1993-2005. WHO Global Database of Anaemia 2008. Iron Deficiency Anaemia. 2001
3. Gasche
C,of
et preparation:
al. InflammatoryOctober
Bowel Dis 2007;13:1545–1553
Date
2014
Causes of IDA
Rheumatoid arthritis
Inflammation
Connective
tissue disorders
COPD
CKD
CHF
GI cancer
Coeliac disease
Gastritis
Inflammatory bowel
disease
GI bleeding
Menorrhagia
Blood loss
Peri-operative
Haemodialysis
UK/OTH/14/0227
Date of preparation: October 2014
GI infection
Medications
Gastrectomy
Malabsorption
IDA should already be a priority… it is an ACSC
8. Iron-deficiency anaemia
UK/OTH/14/0227
Date of preparation: October 2014
IDA is the fifth most common ACSC
Patients per 100k population
350
300
250
200
150
100
50
0
UK/OTH/14/0227
NHS Information
Centre for Health and Social Care (2013), Hospital Episode Statistic Data (under a commercial re-use licence via Harvey Walsh Ltd)
Date of preparation: October 2014
Why Vifor Pharma UK is involved
• Purchased pseudonymised hospital admission data
(HES) where this is an anaemia diagnosis code
• Initial analysis appeared to demonstrate rising
admissions, particularly non-elective admissions
• Convened leading experts to analyse the data to
provide recommendations on improving anaemia
services
Ferronomics - An economic report on the hidden cost of anaemia management
17
Figure 3.8 Correlation between non- elective admissions for IDA and access
to GP services across CCGs in England
CCG
Ease of making a GP appointment
95%
90%
85%
80%
75%
10.00
21.25
32.50
43.75
55.00
Non-elective admissions per 100k
Each blue dot in each graph represents one CCG in England.
3.2 The cost burden of ID A admissions
As described already, there was a substantial increase in the number of patients admitted to
hospital with a primary diagnosis of IDA between 2010/11 and 2012/13 (Figure 3.1). However,
over this period there was a 17.8% decrease in the total expenditure for managing IDA in
England, from £67.49 million in 2010/11 to £55.48 million in 2012/13 (Figure 3.9). This
represents a cost saving of around £12 million.
To investigate how these savings were achieved, the average costs of different types of
admissions were analysed (Figure 3.9). Although savings were made across all three admission
types (non-elective, elective and day case), the biggest savings were made in reducing the cost of
non-elective admissions: £8.43 million between 2010/11 and 2012/13.
Figure 3.9 Annual costs of a dmissions with a primary diagnosis of IDA
2010/ 11
£70,000,000
2011/ 12
2012/ 13
£67.5m
£54.3m
£55.5m
£52,500,000
£33.5m
£35,000,000
£31.1m
£29.0m
£27.2m
£25.1m
£25.1m
£17,500,000
£2.9m
UK/OTH/14/0227
Date of preparation: October 2014
£2.0m
£1.4m
£0
Total cost
Ferronomics Report 2014 V3.indd 17
Total non-elective cost
Total day case cost
Total elective cost
18/06/2014 15:49
THANK YOU
UK/OTH/14/0227
Date of preparation: October 2014
What does care look like for
anaemia patients in the NHS?
Professor Ceri J. Phillips, Swansea University
UK/OTH/14/0227
Date of preparation: October 2014
IDA is common
• 2-5% of all adult men and post-menopausal women
in UK have IDA1
• Much more common in certain patient groups
– Inflammatory Bowel Disease
– Heart failure
– Rheumatoid arthritis2
• Fifth commonest Ambulatory Care Sensitive
Condition (ACSC)3
1.
2.
3.
Goddard A, James M, McIntyre A and Scott B (2011) ‘Guidelines for the management of iron deficiency anaemia’, Gut 60, 1309-1316
Huang J, Means R (2008) ‘The frequency and significance of iron-deficiency anemia in patients with selected concurrent illness’, The Internet Journal
UK/OTH/14/0227
of Internal
Medicine 8,1
NHSDate
Information
Centre for Health
and Social
Care (2013), Hospital Episode Statistic Data (under a commercial re-use licence via Harvey Walsh Ltd)
of preparation:
October
2014
Ambulatory Care Sensitive Conditions
Patients per 100k population
350
300
250
200
150
100
50
0
UK/OTH/14/0227
NHS Information
Centre for Health and Social Care (2013), Hospital Episode Statistic Data (under a commercial re-use licence via Harvey Walsh Ltd)
Date of preparation: October 2014
IDA impairs QoL
• Associated with fatigue, depression, loss of
productivity and cognitive function
• WHO estimates 20% global loss in productivity due
to IDA1
1, World Health Organization (2014) ‘Micronutrient deficiencies – Iron deficiency anaemia’, http://www.who.int/nutrition/topics/ida/en/
UK/OTH/14/0227
(accessed
June 2014)
Date of preparation: October 2014
Study Methods
• Analysis of secondary data sources relating to IDA
outcomes in England and already published in
literature.
• All data from UK Hospital Episode Statistics (HES).
UK/OTH/14/0227
Date of preparation: October 2014
Analysis Plan
• Utilisation
– Total numbers of patients and hospital spells in which
IDA was coded as the primary or secondary diagnosis
– Sources of non-elective hospital admissions
– Rates of re-admission within 30 days following admission
with a primary diagnosis of IDA
– Total bed days and length of stay (LOS) for elective and
non-elective admissions with a primary diagnosis of IDA.
• Costs
– Total costs associated with each type of admission
(elective, non-elective, day case and re-admissions)
with a primary diagnosis of IDA
• Potential for improvement
– Quality issues
– Potential service improvements and cost savings
resulting from optimal treatment
UK/OTH/14/0227
Date of preparation: October 2014
UTILISATION
UK/OTH/14/0227
Date of preparation: October 2014
Total patients and total hospital spells
16.8% increase
11.7% increase
4.6% increase
9.2% increase
57,234
60,000
49,017
80,000
70,228
52,408
78,427
60,000
IDA Spells
IDA Patients
45,000
75,004
30,000
40,000
15,000
20,000
0
0
2010/11
2011/12
HES Years
UK/OTH/14/0227
Date of preparation: October 2014
2012/13
2010/11
2011/12
HES Years
2012/13
Non-elective spells
Non-elective admissions per 100k
population
60
45
30
15
0
UK/OTH/14/0227
Date of preparation: October 2014
211 CCGs
Non-elective admissions adjusted for deprivation
Non-elective admissions per 100k, adjusted
for deprivation
45
40
35
30
25
UK/OTH/14/0227
Date of preparation: October 2014
211 CCGs
Source of non-elective admissions
Through A&E
Through a GP
Through any other means
60%
Proportion of non-elective patients
+4.9%
45%
-4.5%
30%
15%
0%
2010/11
UK/OTH/14/0227
Date of preparation: October 2014
2011/12
HES Years
2012/13
Non-elective admissions vs GP access
CCG
Linear (CCG)
Ease of making a GP appointment
95%
90%
85%
80%
75%
10
15
UK/OTH/14/0227
Date of preparation: October 2014
20
25
30
35
40
45
Non-elective admissions per 100k
50
55
Mean LOS for IDA
All admissions
Non-elective admissions
Elective admissions
7
6
Average LOS
5
4
3
2
1
0
2010/11
2011/12
2012/13
HES Years
UK/OTH/14/0227
Date of preparation: October 2014
2013/14
Re-admitted in 30 days after non-elective
Proportion readmitting in 30 days following a
non-elective IDA admission
80%
70%
60%
50%
40%
30%
20%
10%
0%
UK/OTH/14/0227
Date of preparation: October 2014
211 CCGs
COSTS
UK/OTH/14/0227
Date of preparation: October 2014
Annual costs of hospital admissions
2010/11
2011/12
2012/13
£87,500,000
£70,000,000
£52,500,000
£35,000,000
£17,500,000
£0
Total cost
UK/OTH/14/0227
Date of preparation: October 2014
Total non-elective cost
Total day case cost
Total elective cost
Mean cost per admission
All
Non-elective
Day case
Elective
£3,000
Average cost
£2,400
£1,800
£1,200
£600
£0
2010/11
UK/OTH/14/0227
Date of preparation: October 2014
2011/12
HES Years
2012/13
Non-elective admissions and cost
Total
Linear (Total)
Non-elective
Linear (Non-elective)
Day case
Linear (Day case)
Cost per 100k population
£350,000
£262,500
£175,000
£87,500
£0
10
15
UK/OTH/14/0227
Date of preparation: October 2014
20
25
30
35
40
45
Non-elective admissions per 100k population
50
55
Total cost per 100k
Total cost per 100k population
£400,000
£300,000
£200,000
£100,000
£0
UK/OTH/14/0227
Date of preparation: October 2014
211 CCGs
POTENTIAL FOR IMPROVEMENT
UK/OTH/14/0227
Date of preparation: October 2014
Prescriptions correlation
PPI
Aspirin
NSAID
Prescriptions per 100k population
180,000
150,000
120,000
90,000
60,000
30,000
0
5,000
10,000
15,000
20,000
25,000
Oral iron prescription per 100k population
UK/OTH/14/0227
Date of preparation: October 2014
30,000
Oral iron vs non-electives
CCG
Linear (CCG)
Oral iron prescription per 100k population
30000
22500
15000
7500
0
10
15
UK/OTH/14/0227
Date of preparation: October 2014
20
25
30
35
40
45
50
Non-elective admissions per 100k population
55
Gastroscopy rates
Percentage of male patients >18
receiving gastroscopy
100%
75%
50%
25%
0%
211 CCGs
UK/OTH/14/0227
Date of preparation: October 2014
Potential savings
Actual cost (2012/13)
£35,000,000
£5.04m
£30,000,000
£2.73m
15% saving
Cost in pounds
£25,000,000
£20,000,000
£15,000,000
£0.66m
£10,000,000
£5,000,000
£0
Non-elective admissions
UK/OTH/14/0227
Date of preparation: October 2014
Day case admissions
Re-admissions costs
Conclusion
• Phase I
• Phase II
– Further analysis of primary care utilisation
– Review diagnostic and treatment protocols
UK/OTH/14/0227
Date of preparation: October 2014
Recommendations
•
•
•
•
To review key statistics relating to IDA within their CCG (e.g. nonelective admissions, LOS, re-admissions, and total expenditure),
bearing in mind the wide variations in these indicators between
CCGs in England.
To focus on reducing the number of non-elective admissions for IDA,
as a key driver for improving quality of care and reducing LOS,
excess bed days and cost.
To review pathways in IDA patients following non-elective hospital
admissions in order to prevent re-admissions (given that non-elective
admission with IDA is a marker for increased likelihood of readmission):
– To re-examine hospital discharge pathways.
– To improve coordination between primary and specialist care.
– To consider renegotiating PbR schemes with providers, with
regard to IDA re-admission rates.
To analyse whether reduced availability of primary care services
may be a causative reason for higher non-elective admissions for IDA
and to put services in place to address this issue.
UK/OTH/14/0227
Date of preparation: October 2014
Where to start? Putting
recommendations into practice
Dr James Kingsland, National Association of Primary Care
UK/OTH/14/0227
Date of preparation: October 2014
Questions?
UK/OTH/14/0227
Date of preparation: October 2014