An intriguing new study by researchers in the UK explores attendance and admissions in various hospital areas, including inpatient – outpatient and emergency department (ED) – by children and up to 24 years olds (children and young people, CYP). The team has released their findings on the medRxiv* preprint server.
Earlier research shows that the use of hospital services in all these areas by CYP has increased markedly, driven by increased expectations of the medical system, a larger population, advances in medical technology, and as such, factors affecting pediatric health. The latter includes a greater chance of survival of premature infants and those born with disabilities or anomalies.
Also, conditions that do not require hospital care (ambulatory-care-sensitive-conditions, ACSC) determine much of the increase in emergency services use by CYP in England and Scotland. Poor primary care capacity, and the absence of preventive services, also contribute to this. Moreover, if medical conditions are not dealt with properly, the number of emergency admissions to deal with long-term conditions will go up.
The fundamental determinants are reliable projections of future population size, ethnic composition and poverty among children in England. The investigators took into account the predicted rise in child poverty from 30% to 37% over the period 2017 to 2021 and considered three scenarios of stable, decreasing, and increasing poverty.
*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
ED attendance
The study shows an increase in ED use across age groups but most steeply in the under-10 age group. The highest attendance was in London, the North-East and the North-West of England. CYP from the poorest groups were at greater odds for ED attendance and for admission, planned or emergency, during this period.
Among children below four years, most ED admissions are due to ACSCs, which make up eight of the top ten causes. The five leading causes include respiratory and other infections and fevers.
In the group between 5 and 24 years, injuries progressively made up a smaller proportion of the reasons for admission. ACSCs were the leading cause from 5-9 years, but infectious diseases increased. In the rest of the group, vague illnesses, diseases of the neurological system, and illnesses of the digestive or renal system made up most of the causes.
Planned admissions
Day case admissions went up, and elective admissions dropped, leaving overall non-emergency admissions stable. Most admissions in the very young, below 4, were for conditions present at birth or infancy, or for gut disease or chronic lung conditions. Injuries were at the top for the 5-24 age group.
Outpatient attendance
Infants had the most dramatic increase in OP attendance, by 72%, compared to increases by less than 50% in other age groups. The poorest segment showed the least increase, for infants and for CYP above 20 years. Other age groups showed the highest attendances among the most deprived.
Projections showed increases of almost 90% in the infant and 5-9-year groups, almost 125% in 15-19-year-olds, and about 60% in those aged 10-14 years.
Changes with poverty
Total admissions were projected to rise by 2040, with the bulk coming from ED admissions, if stable poverty was expected. The largest rise was expected among infants, at almost 60%, while 15-19-year-olds would have only a rise of 4%.
Conversely, with decreasing poverty, admissions would still rise, but to a slightly lesser extent. With increasing poverty, admissions would rise by up to 5% more than with stable poverty.
Among those aged 1-4 years only, a shift down the poverty scale would be associated with a rise in hospital attendance by almost a third. Increasing prosperity was projected to lead to only a 6% increase.
Post-COVID situations
The ongoing coronavirus disease 2019 (COVID-19) pandemic put an abrupt end to many factors that drive CYP activity in hospitals and drive a shift to newer modes of healthcare delivery. This includes a reduction in emergency admissions by a quarter, and elective admissions by half, from April to August 2020.
This could be perceived as a golden opportunity to advance such changes to improve future healthcare systems still further. If the current situation is thought to be a ‘COVID shock,’ long-term projections are not affected.
Integrated care
A key component in plans to reduce unnecessary hospital use by CYP while improving ACSC is the provision of integrated care. The researchers estimated the effects of integrated care scenarios that would see ACSCs being treated outside the hospital.
Integrated care aims to provide more services outside hospitals at the interface between primary and secondary care and increase integration across health and social care, with increased attention to prevention.”
If this is fulfilled, the most obvious outcome would be fewer emergency admissions and ED use. The greatest benefit would be observed in the under-10 group, with moderate to high integrated care programs. Infant admissions and ED visits would be projected to decrease by over a fifth to a third.
With high integration, a decrease of 45% to 50% would be expected among those aged 0-9 years.
What are the implications?
Trends showing steep increases in all hospital attendances and admissions, especially in the under-10 group, but observed throughout the 0-24-year age group, were obvious throughout England.
London, the North-East and the North-West of England showed a persistent rise in hospital use, while sub-average figures were seen in the East, South-West, and South-East of England. Interestingly, ED attendances were high in London, but with low ED admissions.
Except in infants, attendances and admissions were comparable at all economic levels. Infants showed higher OP visits, while ED admissions in young children are mostly due to ACSCs that need not have been taken to the hospital. If this is reduced by even 50%, the benefits would be valuable.
The current study is the earliest to make use of current data to predict the future use of healthcare services by CYP up to 2030 and 2040, for any country. The investigators project a continued rise in the use of these services over the next 20 years. This would come to an increase of 50-145% in ED attendances and 20-125% increases in OP attendances.
The study also points to the shortage of CYP services in England, despite the great strain of increased attendance.
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, reducing strain in the system whilst improving outcomes for CYP and family and young people’s experience of care.”
With high integrated care, total admissions could fall to 2007 levels, by 2040. ED admissions could fall to those of 2017 by that time. Effective mitigation of poverty among children is also an essential component of the plan.
Integrated care has been starred as high-priority by the NHS England Long Term Plan at the start of 2019, but delays have occurred with the ongoing pandemic. The latter has also brought a welcome shift in healthcare practices, however. It is hoped that these can be taken forward to reduce unnecessary hospital activity while still providing adequate healthcare.
*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
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