Towards new definitions of avoidable hospital admissions

Abstract

often represents a major upheaval, with potential for physical, psychological, social, and economic consequences. Hospital admissions are also associated with an increased risk of adverse consequences to both physical and emotional wellbeing. Indeed, the broader negative impacts of the ‘allostatic stress’ of an admission may even outstrip those of physical illness in depleting reserves — a risk that persists beyond discharge.1 In patients with frailty, even a short so-termed ‘ambulatory’ admission is associated with increased mortality and subsequent use of health resources.2 While a hospital admission is rarely relished, there is evidence across international health systems that the COVID19 pandemic has heightened peoples’ desire to stay out of hospital, with an increasing trend of patients delaying or avoiding seeking urgent care altogether for fear of being admitted.3 While specific worries about hospitalacquired infection are undoubtedly a component, it appears that people may be more broadly re-evaluating the pros and cons of unscheduled hospital care as part of their re-framed priorities in the postpandemic era. These new sets of priorities, combined with a renewed urgency (driven by unprecedented demand) to explore alternative models of unscheduled care that don’t require inpatient stays, mean we may need to look again at how we conceptualise the avoidable admission. A major challenge of research in this area is the lack of a single, consistently applied definition of an avoidable admission.4 Academics and clinicians alike have long sought a concise and utilitarian way to define exactly who these patients might be, and in which circumstances alternative care is practical and appropriate. One approach is to define this cohort according to a disease or illness for which there exists a viable care pathway that does not require an inpatient stay. Ambulatory care sensitive conditions (ACSCs) are one such classification, defining conditions where effective person-centred community care may prevent the need for hospital admission.5 Along with others, we have previously utilised a nuanced version of this definition — primary care sensitive conditions (PCSCs) — in which the list of conditions is extended to include ‘situations’ that may not themselves be diagnoses or illnesses, but which may be amenable to timely and holistic primary care input to avoid an admission (for example, social care crises).6 Similarly, the term urgent care sensitive conditions (UCSCs) has been used in the literature to describe when same-day urgent care may prevent further resource use,7 although the definition of urgent care is not itself universally agreed. Basing the study of avoidable admissions on ASCSs alone, however, results in an incomplete understanding of the phenomenon. Recent analysis identified a complex relationship between ACSCs, admissions, and ‘preventable’ emergency care.8 The potential ability of primary care to decrease the number of admissions due to ACSCs (and PCSCs/UCSCs) is confounded by the sheer variation in the way services are delivered9 — heterogeneity, which has been further compounded by the COVID-19 pandemic. Even the relationship between availability of GPs and emergency admissions is not straightforward,10 suggesting that it is not just a primary care capacity issue.