This is the 155th #WILTW
Co-inciding with the opening of our new Emergency Department was the release of “Emergency hospital care for children and young people“. Produced by the Health Foundation and Nuffield Trust the report analysed Hospital Episode Statistics (basic data relating to a patients’ admission to hospital) over a 10 year period. It is a sobering read with a headline figure that, although attendances in the under 25s increased by 14% (compared to 20% in all ages), in the under 1s the figure was 30%. These increases over time are no surprise to us with the figure below our own local data from the last 4 years (thanks to Dr. Gareth Lewis for this)
The reasons for this persistent upward spiral are not clear. It is important to note that a large amount of the total change is actually due to population growth and an increasing birth rate. However the birth rate has slowed in the last few years whereas admissions haven’t. Increasing parental anxiety, poor or inequitable access to local health care services and a risk averse medical culture have all been suggested as causes, but whatever the underlying problem is, it’s definitely going to need more than one solution.
The data presented gives an indication of where research and improvement work needs to focus as long as we are aware of some of the challenges in interpreting the figures. Large scale data analysis projects like this are very dependant on the quality of data entered. Healthcare has not had a brilliant track record in recording, or more precisely ‘coding’, information about patients effectively. This is generally because doctors aren’t trained in how important this is and are therefore quite ambiguous in their clinical records. Hospitals employ teams of clinical coders to read notes (and decipher handwriting) so they can record the key outcomes related to a patient’s stay. To make the coders job either they collate conditions into particular predefined and agreed categories. The most common of these are shown in figure 3.6 from the report.
Notwithstanding the complexity of being able to extract information about the underlying condition there are some interesting trends here. I am most taken by the huge increase in numbers of children diagnosed with a viral infection. The authors note:
“– in particular, the large increase in emergency admissions for viral infection and acute bronchitis, as well as the increase in admissions for other perinatal conditions (feeding and respiratory problems) and haemolytic and perinatal jaundice in infants. These may be related to more children surviving with complex disabilities and requiring more intensive healthcare support”
Children with chronic illness are more susceptible to the adverse effects of even the most simple viral illnesses so it is very plausible that an increase in children with complex needs will result in greater presentations with viral infections. The increase in number of viral illness cases seems so large though, especially given that other upper respiratory infections and acute bronchitis* are also predominantly caused by viruses, that either we are in the middle of some unrecognised ‘viral’ epidemic or there are some cultural issues at play. There is no evidence that viruses are being more virulent (length of stay is actually decreasing) and we have been using vaccines for flu and rotavirus (the bug that causes gastroenteritis) for a while.
So we have a challenge. A challenge that is not for any one individual organisation, committee, institute or group to solve. It is not sustainable to have a continued 4% rise in presentations to emergency care year on year so systems need to start talking to each other and the public. They need to discuss not only how to continue to provide quality care given the increasing pressures but to really start to look at the underlying reasons behind these trends so we can continue to give children and young people the most effective care when they most need it.
*note acute bronchitis is not a term I use or really recognise. It is used here to describe a number of different types of short lived chest infections
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Your comments about “acute bronchitis” are interesting and timely. On Wednesday I was in Germany visiting the EU arm of Southampton medical school. The students were asking about the difference between obstructive bronchitis and bronchiolitis as our course talks about the latter but their clinicians frequently diagnose the former.
Apparently obstructive bronchitis is a more traditional diagnosis over there. There was a shift towards diagnosing bronchiolitis and this would attract a higher payment from insurance companies by around €300. Therefore, the insurers have pushed for a reversion to the older diagnosis.
None of this tells us what is actually going on in the lungs though.
Thanks James – really interesting insight (presume this may be lost after Brexit???). Fascinating that payments for coding does actually exist in the NHS it’s just that no one seems to have realised how important it is for individual departments!