Earlier in 2018 we published our first insight on Impactibility, which attempted to look briefly at some of the elements to consider when defining care programmes with the greatest impact.
In particular, we stressed the importance of understanding the non-clinical aspects of patient lives. For example, the clustering of certain conditions in areas of high deprivation also frequently correlates with higher use of the urgent care system than would be predicted from clinical considerations alone. Schemes attempting to reduce the pressure on the urgent care system in such areas must therefore be tailored to support patients in these groups; more ‘traditional’ programmes are less likely to work. Instead, there is firstly a need to recognise that individuals have other life stressor events. These often trigger or compound the need for urgent care and support. At the same time, to work well and sustainably, interventions must use approaches which have been proven to work with similar harder-to-reach groups.
We also highlighted the importance of recognising comorbidities when designing programmes, noting particularly that Chronic Obstructive Pulmonary Disease (COPD), a chronic ambulatory care sensitive condition (ACSC), is frequently found alongside mental health conditions. Therefore, schemes which are aimed at ensuring patients with a diagnosis of COPD and other chronic ACSCs are better cared for in community settings, to reduce unnecessary pressure on A&E, must also consider such common comorbidities.
These observations have been developed further in Population Segmentation, our new introductory guide to methods for identifying and supporting multiple diverse patient groups. As we note there:
There seems a strong argument that to improve the impactibility of interventions addressing several chronic ACSCs, any such programme must also include an additional focus on mental health support services.1
This relates to a more general observation that:
Population health approaches which focus overly on individual conditions and care pathways can be helpful when analysing gaps in care and other aspects of delivery, but they run the risk of missing the full impact of multimorbidity on a population, and particularly the multiplicative impact of mental health conditions on physical health. This again may make it harder to deliver effective interventions.2
These arguments are supported by a recent research paper.3 The authors describe a research study where unplanned admissions were reviewed in primary care through case notes review (a significant event audit, or SEA). Although this was a small-scale study, in their principle findings they note that:
There was disagreement on which admissions might be avoidable when comparing the NHS ACSC list with the list generated by the practice teams using SEA. These findings suggest that the avoidability of unplanned admission may be more dependent on the context-specific factors than the condition. These findings also suggest that in some cases the context may be at least as important as or more important than the diagnosis. The current use of a diagnostic label to identify potentially avoidable admissions (such as the ACSC list) might be problematic as a diagnostic label does not allow for different levels of severity of the condition, influential comorbidities such as dementia, and at which point in time the admission may have been avoidable — the condition may have deteriorated beyond prevention of admission if left ‘too late’.
In their terminology, ‘context-specific factors’ include those relating to patient behaviour, such as ‘presenting at A&E rather than contacting their own GP’ or failing to attend regular check-ups for their condition with the GP. These patient behaviours are more common in areas of higher deprivation.
Understandably, this research concentrates specifically on whether urgent care admissions were preventable through action by primary care alone. However, in concluding that some were not preventable, the authors do not fully discuss the possibility that interventions involving the wider health and care economy could have more impact through, for example, community education and coaching in self-care, the use of managed help lines, investment in social care, and so forth. While there will always be individuals for whom these approaches are also ineffective, they can also help significantly with admission avoidance.
As we have argued elsewhere, such findings may rather suggest that the most impactful interventions are those which are most attuned to the specific clinical and nonclinical characteristics of a patient group. Careful targeting of interventions goes hand in hand with greater impact.
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1 Population Segmentation, page 50.
2 Population Segmentation, page 66.
3 Fleetcroft R, Hardcastle A, Steel N, et al, ‘Does practice analysis agree with the ambulatory care sensitive conditions’ list of avoidable unplanned admissions?: a cross-sectional study in the East of England, BMJ Open, April 2018.