Recent and forecast post-COVID trends in hospital activity in England amongst 0 to 24 year olds: analyses using routine hospital administrative data

  1. Joseph Ward
  2. Dougal Hargreaves
  3. Marie Rogers
  4. Alison Firth
  5. Steve Turner
  6. Russell Viner

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Abstract

Background

Increasing hospital use in the past decade has placed considerable strain on children and young people’s (CYP) health services in England. Greater integration of healthcare may reduce these increases. We projected CYP healthcare activity out to 2040 and examined the potential impact of integrated care systems on projected activity.

Methods

We used routine administrative data (Hospital Episode Statistics (HES)) on emergency department (ED) attendances, emergency admissions and outpatient (OP) attendances for England by age-group for 0-24 year olds from 2007 to 2017. Bayesian projections of future activity used projected population and ethnicity and future child poverty rates. Cause data were used to identify ambulatory-care-sensitive-conditions (ACSC).

Findings

ED attendances, emergency admissions and OP attendances increased in all age groups from 2007 to 2017. ED and OP attendances increased 60-80% amongst children under 10 years. ACSC and neonatal causes drove the majority of increases in emergency admissions. Activity was projected to increase by 2040 by 50-145% for ED attendances, 20-125% for OP attendances and 4-58% for total admissions. Scenarios of increasing or decreasing child poverty resulted in small changes to forecast activity. Scenarios in which 50% of ACSC were seen outside hospital in integrated care reduced estimated activity in 2040 by 21.2-25.9% for admissions and 23.5-30.1% for ED attendances across poverty scenarios amongst infants.

Interpretation

The rapid increases in CYP healthcare activity seen in the past decade may continue for the next decade given projected changes in population and child poverty, unless some of the drivers of increased activity are addressed. Contrary to these pessimistic scenarios, our findings suggest that development of integrated care for CYP at scale in England has the potential to dramatically reduce or even reverse these forecast increases

Funding

Nil funding obtained.

Research in context

Evidence before this study

There has been marked increases in hospital use (inpatient, outpatient and emergency department (ED)) by children and young people (CYP). Search of the PubMed database using the search terms: (((((“child”[MeSH Major Topic]) OR (“adolescent”[MeSH Major Topic])) OR (“infant”[MeSH Major Topic]))) AND ((healthcare use[Text Word])) OR (emergency admission[Text Word])) AND (united kingdom[Text Word]). Drivers of increased activity include population growth and sociodemographic factors, help-seeking behaviour, growth in medical knowledge and capability, and by factors within the health system. Additional factors in child health include increased survival of premature neonates and those with congenital conditions and rising parental expectations of modern medicine. Previous studies have shown that ambulatory-care-sensitive-conditions (ACSC) are responsible for much of the increase in CYP emergency activity in England and Scotland.

Added value of this study

This is the first study to use existing data to project possible future scenarios for CYP healthcare activity out to 2030 and 2040 in any country. Our future scenarios are based upon authoritative projections for population, ethnic diversity and child poverty in England and allow us to estimate the potential impact of integrated care scenarios in which ACSC are treated outside hospital. We show that future projected CYP activity is very high if mitigations such as integrated care are not instituted in England.

Implications of all the available evidence

Healthcare activity has grown dramatically over the last decade in CYP, largely due to ACSC and the consequences of premature delivery. Projections to 2040 suggest that similar increases are likely over the next 2 decades without action to reduce child poverty and implementation of integrated care at scale in the NHS.

Article activity feed

  1. ScreenIT

    SciScore for 10.1101/2021.02.11.21251584: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Projections used the Bayesmh commands and Bayespredict commands in Stata 16 (StataCorp, College Station TX), using weakly informative priors.
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: We used a decade of high quality routine hospital administrative data for England to examine trends in total and cause-specific activity for 0-24 year olds. We modified the GBD cause hierarchy to identify cause groups most relevant to children. Our use of Bayesian probabilistic projections, based upon authoritative population forecasts and potential child poverty scenarios, provided a probability distribution of the quantity of interest. Our findings are subject to a number of limitations. Data for OP attendances and ED attendances are of lower reliability before 2008 and 2012 respectively. Our forecasts are merely possible scenarios for future activity and are necessarily speculative. We were only able to include a very limited number of inputs, which whilst causally related to activity, were themselves forecasts. Our estimates of the impact of greater integration of care were limited to reducing ACSC activity in hospitals and we were not able to examine impacts upon other elements of hospital activity nor on activity in non-hospital settings. It is possible that integrated care models may simply move attendances from hospitals to non-hospital settings. Additionally, these estimates were based upon the assumption that the proportion of ED attendances due to ACSC was similar to the proportion of emergency admissions caused by ACSC. This is likely an under-estimate, given that a greater proportion of less severe cases present to ED than are admitted ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

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  2. Version published to 10.1101/2021.02.11.21251584v1 on medRxiv