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| Journal of the New Zealand Medical Association,
23-June-2006, Vol 119 No 1236
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Avoidable hospitalisations: potential for primary and
public health initiatives in Canterbury, New Zealand
Ian Sheerin, Gary Allen, Mark Henare, Kirsty Craig
The New Zealand health system must make decisions about how
best to spend limited budgets to attempt to cater for ever-increasing demands.
The concept of “avoidable hospitalisations” offers a way of helping
to identify options for spending these health resources on initiatives where
heath gains may be achieved or even maximised.
The concepts “avoidable hospitalisations” and
“avoidable mortality” have been proposed as a way of identifying
hospital admissions and premature mortality that could potentially be prevented
by timely and effective health interventions1. These are theoretical concepts
based on a list of selected diseases and causes of death that are amenable to
early detection and/or preventive measures.
The majority of potentially “avoidable
hospitalisations” involve conditions that could have been identified and
treated earlier by either public health or primary healthcare interventions,
thereby preventing deterioration that may involve a hospital admission or even
death. Examples include lung disease; cervical and breast cancer; traffic
accidents; infectious, cardiovascular, and vaccine preventable diseases; early
detection and excision of melanoma; and effective glycaemic control in people
with diabetes.
The majority of these conditions are amenable to early
diagnosis, prevention, and/or earlier interventions that could potentially
prevent more severe morbidity and save life and health system costs.
The Ministry of Health2,3 found that avoidable
hospitalisations in New Zealand increased slightly during the 1990s, then
stabilised from 2000. However, when this trend was disaggregated, ambulatory
sensitive hospitalisations increased by 25% from 1989 to 1998.2 These were
categorised as diseases that are sensitive to prophylactic or therapeutic
interventions that are able to be delivered in a primary healthcare
setting.2
Other researchers have found that this increase in
potentially avoidable hospitalisations has occurred since at least 1980, and
that there are some regional differentials that are related to ethnic and
demographic factors.4 Indeed, some studies have suggested that there is a link
between avoidable hospitalisations and under-utilisation of primary care,
particularly by lower socioeconomic groups.4,5 Lower income people may put off
going to the doctor until it is too late to avoid hospitalisation.5
The idea of placing more emphasis on early detection and
intervention is related to the concept of
allocative efficiency, which aims to
achieve a more efficient use of resources by providing services in different
ways. This literature indicates the intriguing idea that it may be possible to
achieve a reduction in potentially “avoidable hospitalisations” and
“avoidable mortality” by placing more emphasis on primary-health and
public-health interventions. Although this potential has been noted using
national data, little attention has previously been given to investigating the
extent of avoidable hospitalisations at the regional level, and the total
resources that such admissions may be consuming.
Therefore, Canterbury District Health Board (CDHB) data were
used to estimate the extent of potentially avoidable hospitalisations in
Canterbury, the estimated costs of such admissions, the leading causes, and
recent trends. Such data should be an important consideration for making
decisions about both new investments and how existing services are
configured.
MethodsAll hospitalisations in Christchurch Hospital for
financial years 1 July 2000 to 30 June 2004 were analysed, using data provided
by the Decision Support Unit of the Canterbury District Health Board.
Hospitalisations were categorised using the
International Classification of Diseases (ICD 10) and were identified as
“avoidable” following the definition used by the Ministry of
Health,2 which states that potentially avoidable hospitalisations fall into two
subcategories:
As stroke is an important health
issue in its own right, stroke was recorded as a category distinct from other
cardiovascular disease for the purposes of this study.
Identification of an admission as potentially
“avoidable” was based on the primary diagnosis. Comorbidities and
secondary discharge codes were not taken into account. Consistent with the
Ministry of Health2 definition, hospitalisations of people aged 75 years and
over were excluded from the analysis.
The costs of hospitalisations were estimated using
diagnostic-related groups (version New Zealand DRG WEIS 8B). ICD codes were
mapped across to the corresponding DRG codes to obtain average lengths of stay
by admission, and the appropriate DRG payments were multiplied by the number of
admissions to obtain an estimate of their total costs. Costs of hospitalisations
were estimated for the financial year ending 30 June 2003.
Data was analysed using Microsoft Excel
spreadsheets.
ResultsFindings and
trends—In 2003, 31% of
admissions to Christchurch Hospital were categorised as potentially
“avoidable hospitalisations.” By far the largest category was
cardiovascular disease, which comprised over 8000 of the total 66,399 admissions
in Canterbury in 2003, and 40% of all avoidable hospitalisations. The next most
frequent causes of avoidable admissions were gastrointestinal (17%), respiratory
(9%), stroke (7%), and urinary disorders (9%) [Figure 1]. Comparatively small
numbers of admissions were due to cervical, breast, and colorectal
cancers.
Figure 1. Major categories of avoidable admissions to
Christchurch Hospital in 2003
 Note:
Hospitalisations were for the financial year ending 30 June 2003.
The trend has been for increasing numbers of cardiovascular
admissions from 2002 to 2004 (Figure 2), which reflects total numbers of
admissions for people aged under 75 years, and does not control for possible
age-specific trends. Numbers of admissions for respiratory and urinary disorders
have demonstrated a similar increasing trend (Figure 3).
In contrast, admissions for gastrointestinal disorders have
declined since 2003. While other diseases were comparatively less frequent, some
of them have shown a trend of marked increases from 2001 to 2004, notably for
liver disease and diabetes (Figure 4).
Given the increasing prevalence of both liver disease and
diabetes, continued increases in hospital admissions can be expected in future,
unless effective policies are implemented that are aimed at earlier intervention
and prevention.
Figure 2. Trends in total cardiovascular admissions:
2001 to 2004
 Note:
Admissions were for the financial years ending 30 June, for each of the years
2001 to 2004.
Estimated costs of
potentially avoidable admissions—Total estimated costs of
potentially avoidable admissions to Christchurch Hospital in 2003 were NZ$96.6
million (Table 1). Cardiovascular disease (excluding stroke) accounted for 52%
or $50.6 million and an estimated 34,390 bed days (Table 1).
Stroke accounted for a further $6.1 million and 12,160 bed
days. Following (in descending order of cost) were ear, nose, and throat (ENT);
respiratory; urinary; gastrointestinal disorders; accidents, poisonings, burns;
and colorectal (Table 1).
Ranking in order of estimated total costs provides some
changes in ranking compared with that obtained from total numbers of
hospitalisations. The most notable are costs of ear, nose, and throat
conditions, which rank third in order of total costs (Table 1), although they
are comparatively low in actual numbers of admissions (Figure 1). Similarly,
costs of colorectal admissions are high relative to their lower volumes shown in
Figure 1.
Figure 3. Trends in total admissions for respiratory,
gastrointestinal and urinary disorders: 2001 to 2004
 Figure 4. Trends in total admissions for diabetes,
liver, and infectious diseases: 2001 to 2004
 Table
1. Estimated costs of avoidable admissions to Christchurch Hospital in
2003
Note:
Hospitalisations were for the financial year ending 30 June 2003.
DiscussionThe concept of potentially “avoidable
hospitalisations” helps to highlight opportunities for health
interventions that may make a difference. It indicates the categories of
morbidity that could potentially be targeted in public health and/or primary
care settings. The proposal is that through earlier identification and
intervention there are opportunities to prevent more advanced disease that may
involve hospitalisations or deaths.
This data shows that, in Canterbury, by far the largest
number of avoidable hospitalisations are for cardiovascular disease, involving
estimated costs of over $50 million in 2003 and over 34,000 bed days.
Recently, the New Zealand Guidelines Group (NZGG)6, 7
recommended more systematic screening and management of cardiovascular risk
factors. Indeed, given the prevalence of cardiovascular disease, and the
available options for preventive interventions, primary health care
practitioners are well placed to play a key role in such a strategy.
The main components recommended in the NZGG guidelines were:
The data presented in this paper reinforces the
importance of cardiovascular disease that has been highlighted by other studies,
and indicates the high costs of cardiovascular admissions in one of New
Zealand’s largest district health boards.
Cardiovascular disease has been well documented as being the
leading cause of premature mortality and disability.2 A recent New Zealand study
has noted suboptimal management of risk factors in a sample of patients with
known cardiovascular disease.8 Only 30% of patients met all prevention targets,
thus indicating the potential for a partnership between secondary and primary
care providers with the aim of improving management of risk factors and
preventive strategies.
Previous research has ranked respiratory disease as the
fifth leading cause of premature mortality and disability for the total New
Zealand population.2 This study also found that, in Canterbury, respiratory
disorders are one of the most important causes of avoidable hospitalisations
(Figure 1).
The Ministry of Health9 ranked chronic obstructive
respiratory disease (CORD) and asthma as highly modifiable (using evidence-based
medicine). Guidelines have been developed for improved management of respiratory
disease in the community, with general practitioners playing a key role.
Respiratory disease is currently not identified as one of New Zealand’s
health goals. However, because it is amenable to intervention and is a major
cause of hospitalisation, consideration should be given to making it a higher
priority.
Much of the literature on “avoidable morbidity,”
indicates that there is considerable opportunity for improving allocative
efficiencies in healthcare by investing in initiatives which have the potential
to make a difference in improving outcomes.
The idea of allocative
efficiency involves providing services in different ways with more
emphasis on earlier detection and intervention in order to prevent or slow the
development of more severe disease. Examination of the main types of avoidable
hospitalisations indicates that such initiatives should focus on cardiovascular
disease, stroke, gastrointestinal, respiratory, and urinary disease (Figure 1).
As shown in Table 1, more than $75 million was spent on
hospital care for these categories of admissions in Christchurch Hospital in
2003. Although these were the top five causes of such admissions, there is
evidence of trends of continuing increases in admissions for other diseases,
particularly for diabetes and liver disease (Figure 4).
There is an ongoing debate about whether new investments
should emphasise secondary care such as angioplasty, or primary care such as
improved lifestyle and management of high blood pressure and cholesterol.
However, there is increasing evidence that improved health care in community
settings can lead to better health outcomes and this should involve a
partnership between secondary care, primary, and public health providers.
For example, a 2002 UK National Heart Forum study estimated
that coronary heart disease incidence could be reduced by 30% by relatively
modest changes in peoples’ cholesterol levels, blood pressure, physical
activity as well as by smoking cessation.10 Also, two New Zealand studies have
demonstrated that “avoidable admissions” can be successfully managed
in primary healthcare settings.11,12
From 2002 to 2005, the New Zealand Government has committed
over $400 million to the Primary Healthcare
Strategy, with the major aim of reducing patients’ out-of-pocket
costs of attending consultations with general practitioners. While reduction in
financial barriers to access is an important goal, consideration should also be
given to targeting some of this investment to detecting and managing common
health problems that are amenable to intervention, such as cardiovascular
disease. There is good evidence that this can be achieved
cost-effectively.13
There will be challenges to placing more emphasis on
prevention and earlier detection, with one of the major ones being how to fund
these services. A possible option would be to target new investment in primary
care specifically to preventive programmes, rather than the present strategy in
which the new funding seems relatively untagged in the hope that it will flow on
to lower patient co-payments.
A further option would be to improve the funding of public
health programmes that could complement primary care strategies aimed at
lifestyle changes such as quitting smoking as well as improvements in diet and
physical activity. Historically, public health has received less than 4% of the
Vote Health package (money allocated by
the Government to health in its budget), despite contributing to major
reductions in morbidity during the twentieth century. Such strategies would not
involve major re-allocation of resources from curative services, rather they
imply changes in emphasis and thinking.
The New Zealand health system has devoted much energy over
the past 20 years to technical efficiencies—by reducing costs of overheads
and service delivery. The data in this study, and in other research on
“avoidable admissions,” suggest that there may also be major
opportunities to improve allocative
efficiency by investing in initiatives that emphasise earlier detection
as well as public health and primary health interventions.
CDHB is undertaking initiatives in some of these areas, in
conjunction with primary health providers. A pilot project is being planned to
screen for cardiovascular risk factors in some general practices. A revised
manual is being trialled for rehabilitation of patients with cardiovascular
disease.
Improved detection and management of diabetes is a major
priority. Respiratory disease has also been recognised as a priority and a
project is being planned to provide community spirometry services. These
projects are important steps towards public and primary health initiatives that
will promote earlier detection and management in community settings.
Author information:
Ian Sheerin, Health Economist and Senior Lecturer, Department of Public
Health and General Practice, Christchurch School of Medicine and Health
Sciences, University of Otago, Christchurch; Gary Allen, Mark Henare and Kirsty
Craig, Analysts, Planning and Funding Division of the Canterbury District Health
Board, Christchurch
Acknowledgements:
The
Canterbury District Health Board provided the data for this project. The authors
also acknowledge the assistance of Keith Young and the team of the Decision
Support Unit in providing the project data.
Correspondence: Ian
Sheerin, Department of Public Health and General Practice, Christchurch School
of Medicine and Health Sciences, University of Otago, PO Box 4345, Christchurch.
Email ian.sheerin@chmeds.ac.nz
References:
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