Data manipulation: Activity variables

The care needs of a patient depend both on the type of care needed as well as the volume.

The database therefore contained activity counts for the main types of care. Types of care were defined based on their setting rather than the specialism or procedure involved, to serve the purpose of informing the design of integrated care models that cut across settings. It follows the patient-centred approach, based on where the patient needs to go to receive care.

Care utilisation was measured over five years, to reduce random variation in utilisation and increase the chance of observing low frequency activity.

66 5.4.1 Acute care activity

In the inpatient acute dataset, activity was counted split by elective day cases, elective inpatient hospitalisations, non-elective inpatient hospitalisations and regular attenders, according to common NHS practice.^{133, 134} These variables were defined as detailed in Table 13.

Table 13: Definitions of inpatient care activity metrics Admission

type Abbreviation Definition¹³³ Coding in HES^{133, 135} Elective

day case ELDC “where the patient has a planned admission and is discharged on the same day”

Patient classification is 2 (Day case admission)

Elective

inpatient ELIP “where the patient has a planned admission to hospital with the

expectation that they will remain in hospital for at least one night”

Admission method is 11 (Elective: from waiting list) or 12 (Elective: booked) or

NEIP “where the patient has an unplanned admission. not 11 (Elective: from waiting list) or 12 (Elective: booked) or

attender RA “patients admitted

electively during the day or night, as part of a planned series of regular

admissions for an on-going regime of broadly similar treatment and who are discharged the same day or next morning”

For every patient, a count of ELDs, ELIPs, NEIPs and RAs was calculated over the study period. In addition, the average length of stay (ALoS) in days for elective and non-elective inpatient stays were calculated to quantify healthcare needs further.

Emergency hospitalisations – non-elective inpatient hospitalisations where the admission method was through A&E or an emergency referral by GP, consultant or other specialist – are monitored by the HSCIC on a monthly basis,¹³⁶ and are often used for risk stratification analyses. They were therefore included in the database as an alternative measure to NEIPs.

Nevertheless, the two are closely related, and 79% of NEIPs in the dataset could be defined as emergency hospitalisations (the remainder include hospital transfers, maternity

admissions, babies born in the hospital and admissions where the method was unknown).

Emergency hospitalisations were defined according to NHS standard practice as detailed in Table 14. All other admissions were considered non-emergency hospitalisations.

Table 14: Definition of emergency hospitalisations

Name Definition Coding in HES¹³⁶

Emergency

hospitalisation “episodes with an admission method indicating the

hospitalisation was an emergency”

Admission method is 21

(Emergency: via A&E services) or 22 (Emergency: via GP) or 23 (Emergency: via Bed Bureau) or 24 (Emergency: via consultant outpatient clinic) or 25

(Emergency: via Mental Health Crisis Resolution Team) or 28 (Emergency: via other means)

A count of outpatient appointments was also included in the dataset, as well as the number of unique specialties attended as an outpatient, as defined by the treatment specialty variable in HES.

5.4.2 Primary care activity

In the primary care dataset, activity counts were included for consultations and prescriptions.

Consultations were classified as clinic consultations, surgery consultations, telephone contacts and home visits, as derived from the type of consultation “COT” code in CPRD (see Table 15). The study considers these activities separately as they require different levels of resources, and their unit cost are available from the Unit Cost of Health And Social Care study.¹³⁷ Actions taken by the GP that do not involve direct patient contact were excluded from the patient activity counts. No distinction was made between patients visiting their own GP or a local rota or other service, as the subject of study is the patient and their needs rather than the provider.

68 Table 15: Definitions of primary care activity metrics

Activity COT codes included Surgery

consultation 7 (Out of hours, Practice), 8 (Out of hours, Non Practice), 9 (Surgery consultation), 18 (Emergency Consultation), 33 (Triage), 34 (Walk-in Centre), 36 (Co-op Surgery

Consultation), 38 (Minor Injury Service) Clinic

consultation 1 (Clinic)

Home visit 2 (Night visit, Deputising service), 3 (Follow-up/routine visit), 4 (Night visit, Local rota), 6 (Night visit, practice), 11 (Acute visit), 24 (Children's Home Visit), 27 (Home Visit), 28 (Hotel Visit), 30 (Nursing Home Visit), 31 (Residential Home Visit), 32 (Twilight Visit), 37 (Co-op Home Visit), 50 (Night Visit) Telephone contact 10 (Telephone call from a patient), 21 (Telephone call to a

patient), 35 (Co-op Telephone advice), 55 (Telephone Consultation)

Excluded 0 (Data Not Entered), 5 (Mail from patient), 12 (Discharge details), 13 (Letter from Outpatients), 14 (Repeat Issue), 15 (Other), 16 (Results recording), 17 (Mail to patient), 19 (Administration), 20 (Casualty Attendance), 22 (Third Party Consultation), 23 (Hospital Admission), 25 (Day Case Report), 26 (GOS18 Report), 29 (NHS Direct Report), 39 (Medicine Management), 40 (Community Clinic), 41

(Community Nursing Note), 42 (Community Nursing Report), 43 (Data Transferred from other system), 44 (Health Authority Entry), 45 (Health Visitor Note), 46 (Health Visitor Report), 47 (Hospital Inpatient Report), 48 (Initial Post Discharge

Review), 49 (Laboratory Request), 51 (Radiology Request), 52 (Radiology Result), 53 (Referral Letter), 54 (Social Services Report), 56 (Template Entry), 57 (GP to GP

communication transaction), 58 (Non-consultation medication data), 59 (Non-consultation data), 60 (ePharmacy message)

For prescriptions this study counted both the total number of prescriptions, to reflect the volume of demand on the healthcare system, as well as the number of unique types of prescriptions, to reflect the variety of care needs. Unique prescriptions were defined based on the first 6 digits of the British National Formulary (BNF) code, the BNF Paragraph, which defines the type of drug product.¹³⁸

5.4.3 Patients in residential care

Patients in residential care, such as care homes or nursing homes, receive additional care services that cannot be quantified from CPRD or HES data. Moreover, there is no indicator in either CPRD or HES that confirms a patient is in residential care. Therefore, this care type could not be included in the utilisation patterns. Nevertheless, the fact that these patients are in residential care will influence the volume and type of other care that is received. A

residential care flag was therefore created, which was used to understand clusters post-hoc.

To create the residential care flag, three different sources were used: admission source information from HES, Medcodes from CPRD, and consultation types from CPRD (see Table 16). Admission source rather than discharge destination was used in HES, to pick up patients

who generally reside in a care or nursing home, and not those that get discharged there for temporary rehabilitation. To define the eligible Medcodes, the long-list was scanned for mentions of ‘care home’, ‘nursing home’ and ‘residential care’. Finally, patients were identified who had had a consultation classified as nursing home visit or residential home visits.

Patients were flagged as receiving residential care if any of these three sources indicated residential care.

Table 16: Definition of residential care flag Medcode Description

7653 Seen in nursing home 10993 Discharge to nursing home 13359 Lives in a nursing home 24828 Nursing home care

27936 Delayed discharge to nursing home 43915 Discharge to private nursing home 73083 Nursing home visit note

73321 Nursing home

94070 Provision of continuing care in nursing home 102230 Nursing home acquired pressure ulcer 102493 Admission to nursing home

102598 Discharge to nursing home

46642 Other residential care homes managed by local authority 49681 Lives in care home

99148 Other residential care home man voluntary/private agents 101078 Patient died in care home

24816 Residential care

53140 Local authority residential care Admission

source code Description

54 NHS run nursing home, residential care home or group home 65 Local authority Part 3 residential accommodation: where care is

provided (from 1996-97)

85 Non-NHS (other than Local Authority) run residential care home (from 1996-97)

86 Non-NHS (other than Local Authority) run nursing home (from 1996-97 to 2006-07)

88 Non-NHS (other than Local Authority) run hospice Activity type

(COT) code

Description

30 Nursing Home Visit

31 Residential Home Visit

There are significant limitations to this approach. On the one hand, it is impossible to tell for

70 on proper coding by GPs and acute trusts. It will therefore likely miss a number of patients whose residential care status was not recorded in the notes. To verify the general accuracy of this method, residential care prevalence in this dataset was compared to national averages.

This study flagged 3.0% of the population over 65 as residential care receivers, compared to 3.2% as recorded by the Office for National Statistics,¹³⁹ which is reasonably close.