Comment

Lifting the mist on ACSCs – identifying real issues draining the NHS

Dr Andrew Goddard (consultant gastroenterologist at the Royal Derby Hospital and Royal College of Physicians Registrar) and Professor Ceri Phillips (professor of health economics at Swansea University and director of research at the College of Human and Health Sciences), examine iron deficiency anaemia and what it means for the NHS.

Iron deficiency anaemia (IDA) affects 2-5% of adult men and post-menopausal women in the developed world.(1) It occurs when the amount of iron being absorbed by the body is less than that being lost, usually as a result of external or internal blood loss, but also through inflammatory responses.(1,2)

Symptoms can be highly debilitating, including fatigue, physical weakness, shortness of breath, elevated heart rate, headache, and difficulty concentrating.(3) IDA is associated with impaired quality of life(4) and reduced functioning,(3) and is linked with both direct (e.g. medicines, hospital beds) and indirect costs (e.g. lost productivity).

IDA is classified as an ambulatory care sensitive condition (ACSC), which means hospital admissions could be largely avoided through improved interventions in preventive and primary care. Hospital admissions for ACSCs represent a marker for the quality of care being provided, and reducing these admissions is an important target for commissioners, both in improving the quality and efficiency of the care provided.(5)

However despite this, IDA remains under-diagnosed and under-treated. A recent audit by the Royal College of Physicians noted that anaemia should be more actively investigated, and the cause identified and treated appropriately.(6)

So how can this situation be improved? Analysing Hospital Episode Statistics (HES) data, we have developed a report entitled ‘Ferronomics: an economic report on the hidden costs of anaemia management’. The aim of this work was to better understand the scale and cost of IDA admissions in England, and to provide recommendations on how they may be lowered.

(Above: Ferrous sulphate (in tablet form), or iron salt, is used to treat IDA.) 

What did the Ferronomics Report uncover?

The report revealed some startling statistics about the burden of IDA on the NHS in England:

• The number of hospital admissions with a primary diagnosis of IDA is rising, up 16.8% from 2010-11 to 78,427 in 2012-13.

• Worryingly, non-elective admissions accounted for 15,420 of these, a rise of 9.3% over the same period.

• Almost a third (31.4%) of patients experiencing a non-elective admission for IDA were re-admitted to hospital within 30 days.

• There were large differences in performance levels between CCGs, including a fivefold variation in the number of non-elective IDA admissions and a fivefold variation in the numbers of patients re-admitted within 30 days following non-elective IDA admissions.

• There was a tenfold variation across CCGs in total expenditure related to managing all IDA admissions (from £33,953 to £329,450 per 100,000 population).

There were also discrepancies in quality of care across England. Using upper gastrointestinal investigation (a recommended practice in all male IDA cases(1)) as a marker, we found that the proportion of appropriate patients actually investigated varied from 20.0% to 98.2% across CCGs.

How can we reduce admissions and save costs?

The key focus should be improving the results of underperforming CCGs. For example, if CCGs with above-mean numbers of non-elective IDA admissions reduced their numbers to the mean, we could eliminate 1,755 admissions and save 8,016 bed days. This equates to a cost saving of around £2.73m and would free up valuable hospital places for patients who need them. If similar improvements were also made in IDA re-admission and day case rates, total potential cost savings would come to £8.43m per year.

Recommendations for IDA

We have developed a number of recommendations for commissioners, as well as clinicians and policy makers (see box-out), to help improve service levels and make efficiency savings. Practical recommendations include: improving coordination between primary and specialist care; re-examining patient discharge pathways; ensuring current diagnosis and treatment guidelines(1) are followed; and reviewing the current lack of indicators for the quality of care provided to IDA patients.

Furthermore, we believe our recommendations provide a valuable guide not just for keeping IDA patients out of hospital, but also for patients with other ACSCs. Through achieving this, we can greatly improve service levels and help make widespread efficiency savings across the NHS.

Recommendations for improving care and reducing costs

Commissioners

• To review key statistics relating to IDA within their CCG (e.g. non-elective admissions, re-admissions, and total expenditure).

• To focus on reducing the number of non-elective admissions for IDA.

• To review pathways in IDA patients  following non-elective hospital admissions, to prevent re-admissions:

1) Re-examine hospital discharge pathways;

2) Improve coordination between primary and specialist care; and

3) Consider renegotiating ‘Payment by Results’ schemes with providers, with regard to IDA re-admission rates.

Clinicians

• To review diagnostic and treatment protocols for IDA, to decrease preventable non-elective admissions and re-admissions; to re-examine ways in which primary and specialist care can be better aligned, particularly in the follow-up of patients discharged after non-elective admissions.

• To ensure that quality standards in IDA are met (1); to offer appropriate diagnostic work-ups for all patients with suspected IDA; and to provide all IDA patients with appropriate iron replacement therapy.

Policy makers

• To ensure that there is an appropriate framework in place across the NHS in England to provide appropriate care for patients with IDA.

• To review the current lack of specific indicators and targets relating to the quality of care given in IDA, in both primary and specialist care.

References

1. Goddard AF, et al. Gut 2011;60:1309-16.

2. NHS Choices. Anaemia, iron deficiency – Introduction. May 2012. Accessed March 2014.

3. Gasche C. Anemia in Inflammatory Bowel Diseases. Bremen: UNI-MED Verlag, 2008.

4. Patterson AJ, et al. Qual Life Res 2000;9:491-7.

5. Department of Health. The NHS Outcomes Framework 2013/14. 2012. Accessed January 2014.

6. Royal College of Physicians. National clinical audit of inpatient care for adults with ulcerative colitis. June 2014. Accessed July 2014. 

Above: Professor Ceri Phillips (left) and Dr Andrew Goddard (right)

The Ferronomics Report was fully sponsored by Vifor Pharma UK Ltd. Vifor have been involved in the initiation of the Report, its content, its publication, the selection of the authors and the writing of this article.

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