An exciting new study by UK researchers examines attendance and admission in a number of hospital areas, including patients – outpatient and emergency (ED) department – with children and up to 24 year (children and young people, CYP). The team is on their findings about the medRxiv* preprint server.
Earlier research shows that the use of hospital services in all these areas with CYP has increased significantly, driven by greater expectation of the medical system, a larger population, advances in medical technology , and hence, factors affecting pediatric health. The latter include an increased chance of premature infants surviving and those born with disabilities or irregularities.
In addition, conditions that do not require hospital care (sensory-care conditions, ACSC) confirm much of the increase in the use of emergency services by CYP in England and Scotland. The poor capacity of primary care, and the lack of protective services, also contribute to this. In addition, if medical conditions are not treated properly, the number of emergency admissions to treat long-term conditions will increase.
The basic findings are reliable projections of future population size, ethnicity and child poverty in England. The researchers noted the expected rise in child poverty from 30% to 37% over the period 2017 to 2021 and considered three scenarios of persistent, declining and increasing poverty.
ED attendance
The study shows an increase in ED use across age groups but mainly in the under-10 age group. The highest numbers of people served London, the North East and the North West of England. CYP from the poorest groups was more like the presence of ED and for access, planned or emergency, at this time.
Among children under four years of age, the majority of ED admissions are due to ACSCs, which make up eight of the top ten causes. The top five causes include respiratory and other diseases and fever.
In the 5 to 24-year-old group, the gradual injury made up a smaller proportion of the reasons for admission. ACSCs were the leading cause from 5–9 years, but infectious diseases developed. In the rest of the group, obscure diseases, diseases of the nervous system, and diseases of the digestive or renal system were the majority of the causes.
Designed entries
Day case entries went up, and selected entries went down, leaving overall non-emergency entries stable. The majority of admissions were in very young children, under 4, for illnesses present at birth or childhood, or for gut disease or chronic lung diseases. There was injury at the top for the 5-24 age group.
Outpatient attendance
Infants had the largest increase in OP presence, at 72%, compared with increases of less than 50% in other age groups. The poorest section showed the smallest increase, for infants and for CYP over 20 years. Other age groups showed the highest number of poorest people.
Projections showed an increase of almost 90% in the infant and 5-9-year-old groups, nearly 125% in those aged 15-19, and about 60% in those aged 10-14.
Changes with poverty
Total numbers were expected to rise by 2040, with the majority coming from ED entries, if persistent poverty was expected. The largest increase in infants was expected, at nearly 60%, while only 15-19 year olds would have a 4% increase.
Conversely, with poverty decreasing, enrollments would still rise, but to a lesser extent. With poverty increasing, entries would rise 5% more than with persistent poverty.
Among those aged 1–4 years alone, a shift down the scale of poverty would be associated with an increase in hospital attendance of nearly a third. An increase in wealth was expected to increase by only 6%.
Post-COVID settings
The coronary virus pandemic 2019 (COVID-19) abruptly blocked many factors that drive CYP activity in hospitals and drive a shift to newer healthcare delivery methods. This includes a reduction in emergency admissions by a quarter, and half selected admissions, from April to August 2020.
This could be seen as a golden opportunity to bring forward such changes to further develop health care systems in the future. If the current situation is considered a ‘COVID panic’, long-term projections are not affected.
Integrated care
A key part of plans to reduce unnecessary hospital use with CYP while developing ACSC is the provision of integrated care. The researchers estimated the impact of integrated care settings that ACSCs would see on treatment 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 a greater focus on prevention. ”
If this is achieved, the most obvious result is fewer emergency admissions and ED use. The greatest benefit would be observed in the under-10 group, with medium to highly integrated care programs. Infant admissions and ED visits were expected to decrease by more than a fifth to a third.
With high integration, a reduction of 45% to 50% would be expected among those aged 0-9 years.
What is the impact?
Movements that showed a steep increase in all attendances and hospital admissions, particularly in the under-10 group, but observed through the 0-24-year age group, were evident on throughout England.
London, the North East and North West of England showed a steady increase in hospital use, while sub-average figures were seen in the east, south-west and south-east of England. Interestingly, ED attendance was high in London, but with very few ED entries.
With the exception of infants, attendance and admissions were comparable at all economic levels. Infants showed higher OP visits, although ED admissions in young children are largely due to ACSCs that do not require hospitalization. If this is reduced by even 50%, the benefits would be valuable.
The current study is the earliest to use conventional data to predict the uptake of health care services by CYP up to 2030 and 2040, for any country. The auditors plan a continued increase in the use of these services over the next 20 years. This would lead to a 50-145% increase in ED presence and a 20-125% increase in OP presence.
The study also highlights the shortage of CYP services in England, despite the significant pressure for increased attendance.
Our findings indicate that the development of integrated care for CYP at scale in England has the potential to reduce or even reverse these predicted increases, reducing stress in the UK. and at the same time improve outcomes for CYP and the family and young people’s care experience. ”
With integrated high care, total admissions could fall to 2007 levels, by 2040. ED admissions could fall to 2017 levels by then. Effective alleviation of child poverty is also an essential part of the plan.
Integrated care was identified as a top priority by the NHS England Long-Term Plan in early 2019, but there has been a delay in the ongoing pandemic. The latter has also welcomed a welcome shift in health care practices, however. It is hoped that these can be taken forward to reduce unnecessary hospital activity while still providing appropriate health care.
* Important message
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be seen as final, guiding health-related clinical practice / behavior, or treated as fixed information.