Ambulatory Care Experience (ACE) evaluation report
Children and young people (CYP) are more frequent users of Accident & Emergency (A&E) than adults, especially where access to primary care is poor. There are currently 5.5 million A&E attendances by CYP in England, making up 26% of all age A&E attendances. Overall CYP attendances to A&E is projected to increase by 50% to 2030 if current trends are maintained. In 2015/2016, 39% of all hospital admissions in children were classified as emergency admissions. There was an absolute increase of 14% in emergency admissions in this age group and a 30% increase in those under 5 years between 2005/2006 and 2015/2016. This increase was in acute (26% increase) rather than chronic conditions (9% decrease).
Acute bronchitis, upper respiratory tract and intestinal infections, asthma and jaundice (in neonates) are among the 10 most common conditions diagnosed on emergency admission in CYP. These are all considered ambulatory care sensitive conditions for which admissions can be prevented by interventions in Primary Care. Majority of these are considered to be unnecessary and most could have been cared for in their homes. There are already indications that improvements in some areas like telephonic consultation with the GPs,‘virtual wards’ and tele monitoring might lead to reduction in secondary care services.
In Bradford, the ACE (Ambulatory Care Experience) is a standardised service intervention that aims to reduce hospital referrals from primary care to secondary care and allow redirection of CYP attending Secondary Care to more appropriate care back in the community. The service is a collaboration between GPs, the local CCG and Bradford Teaching Hospitals NHS Foundation Trust (BTHFT). It comprises various clinical care pathways for CYP (targeting different age groups) namely; Wheezy Child, Gastroenteritis, Croup to reduce emergency service use i.e. A&E visits and emergency admissions, and Bronchiolitis and Jaundice Pathways to reduce length of stay in hospital. These pathways were planned to launch sequentially during a 12 month period.
The Wheezy Child Pathway was launched in December 2017. So far, three pathways namely, Wheezy Child, Gastroenteritis and Croup have been launched as planned, and Jaundice and Bronchiolitis Pathways are currently being piloted (in February 2020). These pathways provide alternative community-based urgent care and are delivered by a nurse in child’s own home and oncall consultant paediatrician based in the hospital who takes full clinical responsibility for patients in a ‘virtual ward’. Cases can be referred to the service from Primary Care, as well as the A&E and Children’s Clinical Decision Area at Bradford Royal Infirmary (BRI).
Despite national recommendations to increase ambulatory care provision, there is very little research into evaluating the impact of such initiatives. A U.S. study suggested that home visits by community health workers to support adherence to recommended care may be cost effective in reducing health care utilisation by children with ambulatory care sensitive conditions (ACSCs). A recently published Cochrane systematic review of school-based interventions on self-management of asthma (a ACSC) has reported reduction in the number of acute episodes of healthcare usage. This review included studies mostly from the U.S. and none from the UK. Moreover, primary evaluations of the community based interventions to reduce health care use in children with ACSCs in the UK are currently completely absent. Hence, we aimed to conduct a quantitative evaluation of the three ACE pathways on emergency service use (emergency admissions and A&E visits) by CYP.
Assess data usability for the proposed quasi-experimental evaluation of ACE pathways and explore potential comparators
Assess trends/change in trends over time in overall emergency admissions and A&E visits and by sub-groups of diagnoses (ICD-10 diagnoses sub-groups)
Quantify the number of emergency admissions and A&E visits for children (0-16 years) with conditions targeted by the ACE intervention, before and after intervention implementation in BTHFT
Assess the impact of the three ACE pathways on emergency admissions and A&E visits using quasi-experimental approach