Unplanned Returns to Hospital Care: A Linked Data Study Kathy SMITH 1 and Renee IANNOTTI Health System Information and Performance Reporting Branch, NSW Ministry of Health Abstract. The linkage of data across facilities and settings of care provides a holistic view of the patient journey through the healthcare system. This study, through data linkage, reviews alternative approaches to the measurement of unplanned returns to care in NSW public hospital emergency departments and admitted patient care settings. The study shows that existing measures of unplanned returns do not identify the true extent of these events and highlight the need to develop new approaches to measurement using the increasing availability of integrated patient information. Keywords. Representations, readmissions, data linkage, admitted patients, emergency departments, journeys of care, measurement, indicators Introduction The objective of the study was to investigate how the linkage of currently disparate but routinely collected patient data could better inform the understanding of patient’s unplanned returns to care and to demonstrate the potential of using existing data in new ways. For system performance managers the availability of integrated data can overcome known weaknesses of current measures and indicators that rely on restricted views of the patient journey, only taking in activities occurring in a single setting, facility or health service. This often leaves measures open to misinterpretation due to those missing data that may otherwise enrich the view of a patient’s overall healthcare journey. Facilitating linkage between data sources opens up opportunities for new and more meaningful measurement. For measures such as admitted patient (AP) readmissions and emergency department (ED) representations linkage provides the opportunity to explore more realistic views of how patients travel through the healthcare system and the dynamics of how, why, when and where they may return to care. Unplanned representations are measured for a variety of reasons 1,2 including patient safety, demand management and general understanding of the dynamics of care. Patients will make unplanned returns to care for many reasons. Of particular interest is when unplanned representations are unexpected, avoidable and unnecessary, however this is often only clear on individual record review. The primary measurement issue for this study was identifying all unplanned returns to care to provide a consistent base from which more targeted investigation could be undertaken. Traditionally, available data and systems have only allowed us to separately 1 Corresponding Author.
view these returns to care from within single settings such as EDs or AP settings, and within individual health care services. Significant improvements in the availability and timeliness of linked data have allowed a new view of representations to care that follows patient movements within and across the health services. This study makes a comparison of measures of patients returning to care using linked and unlinked datasets. 1. Background There is substantial difference between the methods used to define, measure and report unplanned readmissions 3,4,5,6 . Often this is simply because the focus of interest may vary, resulting in different inclusions and exclusion to the base calculations. Definitions may also be adjusted to address limitations of the available data. The result is, that despite being called “readmissions” the comparability of these measures is not straightforward and often they are not comparable at all. Most studies that examine patients making unplanned returns to care have focused on a single setting, either EDs 7 or AP settings 8,9,10 , and generally target only those patients and events that occur within tightly defined timeframes (e.g. 48 hours and 28 days). Often the focus is only a small cohort of patients with targeted conditions both in the index and readmission event. These scope limiters are often used to increase the likelihood of capturing returns to care that are more likely to relate, or have a causal link to the patient ’ s previous healthcare event. While this may be fit for a particular focused investigation it also removes from visibility many readmissions that should be investigated. In 2014 a revised 28 day all cause unplanned readmission performance indicator was introduced in the NSW public health setting that did not discriminate or attempt to presume the cause of readmission, but simply aimed to identify that an unplanned readmission occurred. This measure however only covers the admitted patient setting and omits the common occurrence of a patient presenting at an ED without having an AP event. The recent improvements in the availability of data linkage facilities across NSW health allowed for a more sophisticated view of patients who readmit as an inpatient and/or represent at an ED following a health care service to be investigated. In NSW 66% 11 of public hospital ED presentations during 2015 involved patients departing from the ED without being admitted. Despite this, few investigations have been undertaken on identifying or measuring ED attendances following an AP stay or on AP stays following ED attendances, particularly in an Australian context. A study in the US by Brennen et al 12 found 18.2% of patients had an ED visit within 30 days of an AP stay. Dinh et al 13 examined readmissions to an AP unit within 30 days of index AP admission from ED as well as unplanned representations to ED within 3 days of discharge from ED. A study by Robinson et al 14 , in a NSW tertiary level ED found 23.7% of patients who represented to the ED required hospital admission. Related investigations were undertaken and published by the Bureau of Health Information 9,10 . Many of the previous studies have been limited by being restricted to readmissions to the same facility as the initial presentation. Davies et al 15 . found that in the US 68% of all-cause readmissions and 70% of 30-day potentially preventable readmissions occurred to the same hospital indicating that at least 30% of readmissions were to a different hospital as the index admission.
2. Methods A retrospective data linkage study was undertaken of all patients presenting to NSW public EDs or discharging from an AP stay at a NSW public hospital between 1 January 2011 and 31 December 2015. The primary data sources were the NSW Admitted Patient Data Collection (APDC) and the NSW Emergency Department Data Collection (EDDC). ED and AP records were probabilistically linked by the Centre for Health Record Linkage 16 (CHeReL) using blocking and scoring to identify matches. The reported quality of the record linkage is less than 5 per 1,000 missed and 5 per 1,000 false positive links. Patients with an AP stay or ED presentation between 1 January 2011 and 31 December 2015 were followed for 28 days following their discharge from hospital or departure from ED to determine if the patient was readmitted or represented for an unplanned event. Data was extracted from the “Admitted Patient, Emergency Department Attendance and Deaths Register” (APEDDR) via SAPHaRI (Secure Analytics for Population Health Research and Intelligence) which is managed by the Centre for Epidemiology and Evidence, NSW Ministry of Health. There are no indicators in the NSW public health system which report on representations to hospital care by combining AP readmissions and ED representations into a single metric. To enable such analysis the concept of a journey of care (referred to as a journey) is introduced This consists of contiguous hospital events beginning when a patient first interacts with a hospital (either in the ED or AP setting) until the patient completes all hospital events in the contiguous series (i.e. until the patient leaves the care of the health system). Some journeys of care may involve multiple contiguous events within one hospital or across many hospitals such as when a patient is transferred between hospitals. Patients with an event that resulted in death (either ED or AP) were included in counts of representation but were excluded as index events. Descriptive analyses using seven methods of measuring readmissions and representations were performed: • two based on AP data only (same facility and any facility readmissions); • two based on ED data only (same facility and any facility ED representations) and; • three based on linked AP and ED data. The two methods using only ED data included ED attendances where the patient was either admitted and discharged as an inpatient in ED or departed treatment completed. Cochrane Armitage trend tests were used to examine the trend in representation rates for each method over the 5 year period between January 2011 and December 2015. A more detailed analysis for a 1 year subset (2015) was undertaken to identify specific issues. Analyses were conducted in SAS Enterprise Guide version 6.1 17 . 3. Results There were 17,127,716 journeys of care between 1 January 2011 and 31 December 2015 for 5,057,028 individual patients. 54.5% of journeys involved ED only, 28.6% involved AP only and 16.8% involved both the ED and AP. 2.0% of journeys involved multiple facilities. The journeys of care resulted in 2,743,969 unplanned representation journeys to either an ED or AP setting within 28 days.
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