Abstract
Background There is little evidence documenting the attitudes, experiences, and behavioural factors of high-risk patients who are associated with avoiding hospital.
Aim To explore the health, healthcare management, and behavioural factors that contribute to enabling high-risk patients to avoid unplanned hospital admissions.
Design and setting This was an in-depth qualitative, primary care, interview study with patients who were registered on the Northumberland High Risk Patient Programme (NHRPP) in Northumberland, UK.
Method There were 30 participants in this study, of who 21 were high-risk patients and nine were carers, spouses, or relatives. A grounded-theory approach was used to explore themes that emerged from the semi-structured interviews.
Results Participants described physical enablers that helped them to avoid hospital including medication, living aids, and resting; however, the benefit of these may be challenged by patient decision making. The strategies that patients used to cope with their health conditions included acceptance, positive reinterpretation, and growth. Participants felt that support networks of family and friends helped them to avoid hospital, although the strain on the spouse should be considered. The majority of patients described having trust and confidence in their healthcare providers, and continuity of care was important to patients.
Conclusion Reinforcing the importance of the physical enablers, as well as support networks to patients, carers, and healthcare providers, could help patients to avoid hospital. Highlighting the coping strategies that patients use may help patients to manage their health, while promoting continuity of care will also contribute to helping high-risk patients to avoid unplanned hospital admissions.
INTRODUCTION
The UK population is increasing and ageing, with a rise of 12%, 18%, and 40% predicted for 2015–2020 in the populations aged >65, >85, and >100 years, giving an increase in 1.1 million, 300 000 and 7000 people in each age group, respectively.1 Because health generally decreases with age, costs to adult social care, community-based health services, outpatient appointments, and non-elective and elective admissions all increase with age. Moreover, those aged >75 years have the greatest cost to health and care services, being close to 28%, 46%, and 89% higher than people aged 65–74, 55–64, and 45–54 years, respectively.2 Additionally, care of people with long-term conditions accounts for 70% of the money spent on health and social care in England.3
With an increasing population of older people with complex comorbidities, disability, frailty, and high social and healthcare requirements, healthcare systems are currently under severe pressure to optimise care while keeping costs down, and this is not just a problem in the UK. Interventions, including care from inpatient geriatric units,4 systems of screening, assessment, referral, and follow-up,5 and detailed assessments and management plans tailored to individual patients by a community multidisciplinary team6 have shown improved health outcomes and physical performance. However, most studies to date have failed to reduce hospital admissions in frail and older high-risk patients compared with usual care.
There is a growing need to develop ways to improve management of high-risk patients and relieve pressure within the healthcare system. Identification of patients as ‘high risk’ of admission to hospital due to frailty with enhanced care planning within primary care is the current consensus, with the aim to improve patient care and reduce unplanned hospital admission. In the UK, the Northumberland High Risk Patient Programme (NHRPP) was introduced as a combined health and social care platform, and included people with long-term conditions and/or those at high risk of hospital admission or readmission.7 However, the specialist geriatric input into primary care multidisciplinary team meetings involved in the NHRPP was felt to have little impact on reducing hospitalisation.8
Why certain high-risk patients are able to stay at home and avoid hospital admission or readmission is currently unknown. Factors such as effective care planning, access to health professionals, and follow-up calls after discharge from hospital8 may help patients avoid hospital admissions. Clinical factors such as patient ability to recover after functional decline,9,10 relapse or complications of their condition,7 low health status,11 low-quality inpatient care,12 and lack of connectivity of care between hospital and the community6 have conversely been associated with more frequent hospital admissions. Social care factors including poor carer support6 and medication management,6,7 as well as patient factors including knowledge or information accessed by the patient,8 self-management, individual health beliefs,8 self-efficacy,13 and lack of physical activity11 have also been associated. Moreover, factors ranging from age discrimination, mental health, and spiritual care have been suggested to have an influence on the health status of frail and older patients.13
How this fits in
Exploring the unknown behavioural factors that are associated with avoiding hospital admissions has the potential to help optimise care for high-risk patients in an increasing population of older people, while reducing healthcare resources and cost implications. The outcomes from this qualitative interview study showed that the physical enablers, such as preventive medicine, daily living aids, and the influence of support networks of family and friends, are important in helping high-risk patients to avoid hospital. Promoting the coping strategies that high-risk patients use in their approach to their health, including acceptance and positive thinking, could be a beneficial solution that may encourage patient self-efficacy. Although difficult to achieve in modern-day general practice, encouraging continuity of care from GPs and other health professionals will contribute to improving the trust and confidence that a high-risk patient has in health professionals, and could help to promote shared decision making, reduce anxiety, and also reduce unplanned hospital admissions.
Although the factors contributing to hospital admission or readmission have been documented, there is little published evidence regarding the attitudes, experiences, and behavioural factors of high-risk patients that enable them to avoid unplanned hospital admissions. Qualitative research has shown that case management of frail older patients14 and specialist input8 within primary care have little effect on hospital admissions. Moreover, access to expertise in the care of frail and older patients was perceived to be a barrier to hospital admission avoidance,15 as were clinical error, delayed care seeking, home care access, and minimal care.16 Because the majority of studies to date have focused on patients who have had multiple hospital admissions, there is a lack of knowledge on the experiences and behavioural factors of high-risk patients who manage to avoid unplanned hospital admissions. Identifying the enablers of avoiding hospital admissions within this cohort can be used to improve their management and increase the population of patients who are able to stay at home and avoid unplanned hospital admissions, improving wellbeing and quality of life, as well as reducing healthcare resource implications and costs.
METHOD
Study design
This is a qualitative, primary care study that used one-off in-depth interviews with patients to explore the experiences, attitudes. and perceptions of high-risk patients (defined as patients who were registered on the NHRPP) about their health and the health care they receive, and explore the behavioural factors that contribute to the avoidance of unplanned hospital admissions.
Participants
GP surgeries were identified through the Northumberland Clinical Commissioning Group, and all 44 surgeries registered on the NHRPP were asked to participate in the study. Fifteen surgeries agreed to take part, and patients were subsequently approached via letter. Subsequently, 22 patients contacted the researcher to take part; however, one patient withdrew from the study before being interviewed owing to poor health.
In total, 30 participants took part in a one-off interview with the researcher: 21 of who were high-risk patients from seven different GP practices; seven were spouses; one was a paid carer; and one was a patient’s granddaughter. In the 12 months before their interview, 13 patients had had no unplanned hospital admissions, whereas, out of the remaining patients, unplanned hospital visits ranged 1–12 admissions (Table 1). All participants were white and spoke fluent English; their socioeconomic class ranged from 1 to 8, where a value of 1 represents higher managerial, administrative, and professional occupations and a value of 8 represents those who have never worked and those who are long-term unemployed.17 Information on whether participants had advanced care directives or ‘do not resuscitate’ decisions were not collected. However, the search strategy that the GP practices conducted for selection of potential participants to be included in recruitment did not involve patients who lacked mental capacity. Other exclusion criteria were age <65 years or no registration on the NHRPP. Inclusion criteria were registration on the NHRPP, and either no unplanned hospital admission in the past year, or return from hospital within the past month with three or more multiple hospital admissions in the previous 12 months.
Table 1. Participant characteristics
Further suitability for participation, such as health status of the patient, was decided by the recruiting GP practices.
Northumberland is a generally high-performing area, with Northumbria Healthcare NHS Foundation Trust rated outstanding in 2016 by the Care Quality Commission, and hospitals were graded ‘good’ or ‘outstanding’.
Additionally, the participating GPs who were recruited had a mean Quality and Outcomes Framework performance total achievement percentage point (2016–2017) of 99.4% (range 98.2–100%).
The study ran from December 2016 until June 2017, and the researcher had not met any of the participants before the interview.
All of the semi-structured interviews took place in the participants’ homes and on average interviews lasted 1 hour. Participants were not paid for their time, and no participants lacked mental capacity. Participant characteristics are shown in Table 1.
Sampling
Using purposive sampling, patients were recruited from large and small GP practices throughout Northumberland to give a maximum variation sample.18 Theoretical sampling using themes emerging from the interviews was performed until data saturation occurred during analysis of interview transcripts.19
Analysis
The interviews were conducted by the first author using an adapted grounded-theory methodology. The final interview topic guide used to lead the semi-structured interviews is available from the authors on request. Interviews were audiorecorded, transcribed verbatim, and anonymised. Interview data were coded by the first author using Microsoft® Word 2010 and conceptualised using constant comparison of the data, with interviews and data analysis occurring in series. As the interviews proceeded, themes that emerged from the data informed questioning in the sequential interviews until data saturation occurred.20 Data analysis, categorising, and inductive re-categorising of themes were performed by the researchers. Transcripts were returned to participants for comments, however, no feedback was received.
DISCUSSION
Summary
Generally, participants felt that the health care they received was excellent. The majority of patients described having trust and confidence in their healthcare providers, and continuity in care from health professionals was important to patients. Moreover, continuity of care could help promote shared decision making and reduce the challenges of patient decision making against or without the advice of a health professional.
Participants perceived that taking preventive medication, having physical aids, adaptations within their homes, living a healthy lifestyle that includes healthy food and exercise, resting, and knowing their limitations were enablers of avoiding an unplanned hospital admission, though the benefit of these may also be challenged by patient decision making. Participants also felt that support networks of families, friends, and/or neighbours helped them avoid hospital and reduced anxiety. Strategies that patients described to cope with their health conditions included acceptance, positive reinterpretation and growth, mental disengagement, and focus and venting of emotions.
These findings show insights into the perceptions and attitudes of this cohort of high-risk patients towards their health and the health care they receive, and provide a deeper understanding of the behavioural aspects that contribute to high-risk patients avoiding unplanned hospital admissions.
Strengths and limitations
This study attempts to highlight the behavioural and attitudinal effects on patient outcomes and hospital admission avoidance. Because this study involved a sample of 21 patients and nine family members or carers from Northumberland, these data may not be generalisable outside the study sample. Moreover, this study reports only this cohort of patients’ own personal self-identified issues. However, the data captured by this study reached saturation within the participant sample and therefore may be transferrable.
It is possible that interviews with carers of high-risk patients who lacked mental capacity would have provided different insights into the attitudes, experiences, and decision making regarding unplanned hospital admission. Additionally, interviews with patients with mental health issues, especially anxiety, may provide a deeper understanding of the influence of emergent themes, notably coping strategies. However, due to the nature of mental health conditions, this group of patients are difficult to recruit for interview studies. Moreover, interviews with GPs, community nurses, and other key health professionals would provide beneficial insights. As with all qualitative studies this project may have been subject to interviewer bias. However, two researchers were involved in the data analysis, and the interviewer did not have medical training or prior medical assumptions.
Comparison with existing literature
Participants in this study described preventive medication as an enabler to avoid hospital, and medication adherence has been shown to reduce readmission rates by more than double when compared with low adherence;21 almost half of avoidable hospital admissions are caused by non-adherence.22 Moreover, adaptations in the home, environmental aids, and assistive technology, as mentioned by participants in this study, may help prevent hospital admissions in patients with dementia23 and patients with a clinical diagnosis of stroke.24
Acceptance was an important coping strategy to participants in this study, and in the literature less acceptance and high avoidance behaviour have been associated with: readmission of patients with ischaemic heart disease;25 significantly higher anxiety and stress levels in chronically ill older patients;26 and greater anxiety and depression in patients living with the risk of serious arrhythmias and sudden cardiac death.27 Moreover, positivity was used by some patients in this study to cope with their health and positive thinking has been found to be used by the majority of patients before cardiac surgery.28 Strategies focusing on problem solving and having a positive outlook are related to lower anxiety levels in patients with traumatic brain injuries and orthopaedic patients.29 Other studies have also found that seeking help from others including family, health professionals, and other patients improved patient outcomes.28,30 Religious coping has also been shown to improve patient outcomes,28,31 which was not found in the present study.
Social support was crucial to patients interviewed in the present study, and has been found to be a key factor in the psychological wellbeing, health, and coping behaviour of older patients with cancer.32 Similar to this study, neighbours as sources of support was documented in a study of patients with ischaemic heart disease.25 Next of kin were important in contributing to older patient’s feelings of safety during hospital admission,33 and male patients with cancer who were married showed less psychological distress and more determination in comparison with unmarried patients.32 Moreover, lack of family support is associated with more hospitalisations in patients with heart failure,34 and social isolation is associated with multiple hospital admissions for older patients with chronic disease.35 It has been documented that family members of older patients with cancer carry financial, professional, emotional, and social burdens,32 and many family caregivers feel overstrained,32 as is also shown in this study.
As mentioned by the present participants, higher continuity of care has been associated with higher levels of trust between a patient and GP,36 and, though not found in this study, patient’s understanding of their illness37 and better quality of disease management38 are also associated with continuity of care. Relationship continuity is related to patients feeling able to cope with their condition, has the potential to improve adherence to medication regimes,39 and high levels are associated with reduced hospitalisations among older patients.40,41 Furthermore, patients who experience discontinuity in their care are more likely to have poor treatment and medicine adherence,37 as well as being more likely to have depression, experience symptoms, and to attend accident and emergency,42 which was also the case for the few patients who reported a lack of confidence in their GP in this study.
Implications for practice
To the authors’ knowledge, this is the first study to demonstrate the enablers used by high-risk patients who successfully avoid hospital admission. The enablers, such as preventive medication,21,22, daily living aids and adaptations in the home,23,24 and support from networks of family, friends, and neighbours,32,33,35 were important to patients, as well as to family members and carers in this research. Acceptance of their current health status and positive reinterpretation adjusting their expectations were strong messages from this cohort. Acceptance of the effects of their health condition and/or old age, acceptance of not being able to do certain things any more, and positive thinking through expert patient, health professional, or caregiver discussions may help receptive patients cope with their health at home and improve self-efficacy.
Promoting continuity of care from GPs and other health professionals by enabling patients to see the same professionals will likely contribute to improving trust and confidence, encourage shared decision making, and improve patient outcomes and wellbeing, and may help to reduce unplanned hospital admissions. Although difficult in modern-day general practice, implementing continuity of care may help support a health system with an increasing number of patients with multimorbidities.