Variation in admissions from hospital emergency departments in the English NHS
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Background
Emergency admissions to hospitals via the Emergency Department (ED) are a growing concern internationally due to their impact on healthcare costs. The aim of this study is to document the variation between hospitals in the English National Health Service in respect of their ED admissions before and after taking account of patient casemix and the primary care environment.
Methods
Fixed-effect regression analysis of 13,888,084 ED attendances from 9,063,518 patients from all NHS hospitals for 2018/19. The primary outcome was the hospital-specific likelihood of a patient being admitted after an ED attendance. Extensive controls were included for characteristics of the patient, their attendance and their GP practice.
Results
On average, 20% of ED attendances resulted in emergency admissions. Significant variation in admission rates was observed across English hospitals, both before and after adjusting for patient and system characteristics. Increased admission likelihood was found for:
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older adults, non-White ethnic groups, and patients from more deprived areas.
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patients arriving by ambulance or during periods when GP practices were closed.
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patients living closer to their GP.
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GP practices for which patients are less aware of extended hours and have higher chronic disease prevalence.
After allowing for controls, considerable unexplained variation in hospital admission rates persisted, ranging from 12% to 35%, with an uneven distribution across the country.
Conclusion
There is substantial and persistent variability in emergency admission rates across English NHS hospitals, after controlling for a comprehensive range of patient and system characteristics. This highlights that a uniform approach to managing admissions may be ineffective and that tailored strategies, considering local resources, patient needs, and hospital-specific capabilities, are essential to reduce unnecessary admissions while ensuring equitable access to essential care. Future research should further explore the roles of alternative emergency care services, patient socioeconomic factors, and broader emergency care infrastructure.
Key messages
The state of knowledge
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Emergency admissions via the ED are a growing concern internationally due to their impact on costs, hospital crowding, and the potential for subsequent admissions.
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Considerable variation exists in hospital admission rates, even after accounting for patient case mix and the overall healthcare environment.
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Existing studies largely focus on predicting whether a particular patient will be admitted from an ED.
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There are few studies that consider variation across hospitals in ED admissions, and those that do were primarily set in the US healthcare system.
What this study adds
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The first in the UK to examine the variation between hospitals in their ED admission rates, accounting for both patient characteristics, the local healthcare delivery environment, and the specific provision of out-of-hospital services at the patient level.
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It highlights that significant, unexplained variation in admission rates persist among hospitals even after extensive controls for patient demographics, socioeconomic status, attendance characteristics (e.g., arrival by ambulance, time of arrival), and GP practice characteristics.
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It identifies specific patient and GP practice characteristics that are associated with higher admission rates (e.g., older adults, non-white ethnic groups, more deprived areas, arrival by ambulance, arrival when GP practice is closed).
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It provides geographical insights into where higher adjusted admission rates persist (e.g., Liverpool, Bradford, Buckinghamshire, and Guildford).
How this study might guide future practise and policy
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The findings suggest that a uniform national approach to managing emergency admissions is likely to be ineffective.
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Policy and practice should adopt tailored strategies that consider local resources, specific patient needs, and the capabilities and policies of individual hospitals to effectively reduce unnecessary admissions.
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It implies that well-placed urgent care facilities and improved transport options could alleviate pressure on emergency services in certain areas.
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The study informs decision-makers with oversight of healthcare systems on where efforts to reduce admissions could be better targeted and provides a basis for identifying examples of successful admission reduction strategies.
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It points to the need for future research to further explore the roles of alternative emergency care services, patient socioeconomic factors, and the broader emergency care infrastructure.
