Interventions needed in areas of high hospital admission rates

by Stephen Duckett

Published by The AgeFriday 22 July

When people end up in hospital for diabetes, tooth decay, or other conditions that should be treatable or manageable out of hospital, it’s a warning sign of system failure. Parts of Australia have had appalling rates of potentially preventable hospital admissions for at least a decade. Addressing the problem is devilishly difficult but it can be done. The Grattan Institute’s new report, Perils of Place, suggests a way.

It would be nice to think that money could be easily saved in the health system by reducing those admissions to hospital that are due to potentially preventable causes. Australian Institute of Health and Welfare statistics show up to 6 per cent of all admissions can be labelled potentially preventable.

But here’s the rub: while those admissions include some that should indeed be preventable – admissions for measles are an example – in others preventability is not so clear cut. For example, an admission for a chronic disease that has worsened significantly and that leads to a length of stay of 10 to 15 days may not have been preventable, even with the best primary care in the previous few months.

Admission rates for potentially preventable conditions vary dramatically throughout Australia. A quick fix to eliminate all potentially preventable admissions is unrealistic. A reasonable target is to reduce rates in high-rate areas closer to the national average, creating a virtuous cycle of improvement.

Perils of Place looks at whether it is possible to identify areas with high rates of these admissions, and if so, what can be done to bring them back to average or better. Using data from Queensland and Victoria, the report shows only half of those areas with high rates of admission in a year still have high rates in the next year. There is thus considerable noise in these data, making designing interventions that much harder.

To top it off, there is only limited evidence on what interventions actually work to reduce potentially preventable hospitalisations. This is not a policy field into which we should be leaping blindly. Setting simplistic policy goals to eliminate potentially preventable admissions, with accompanying unrealistic targets, does not make good policy.

Because the causes of the problem vary significantly nationwide, the reasons for high rates of potentially preventable hospitalisations in Mount Isa in Queensland are unlikely to be the same as for Ferntree Gully or Broadmeadows in suburban Melbourne. In our data we found that rates in some areas were caused mainly by readmissions (a small number of people frequently returning to hospital), while readmissions were not a factor in others. Centrally designed programs therefore won’t work, but centrally designed evaluations are essential, so that lessons from locally designed interventions can be shared nationally.

The report’s title, Perils of Place, has a double meaning. We identified some places in Queensland and Victoria that are indeed perilous for health and must not be ignored. These places had high rates of admissions for potentially preventable hospitalisations for 10 years in a row. We were conservative in our definition of “high rates”, setting the threshold at 50 per cent above the state average. These are the places where health inequalities are already entrenched and, without intervention, are most likely to endure.

But place-based strategies can be perilous, too. Our analysis shows how easy it is to focus on the wrong places and spend wastefully if one relies on just a year of data. We support locally designed trials and interventions, preferably led by the Primary Health Networks working with local health authorities and communities. In one place, a focus on people who return frequently to hospital might be appropriate; in another, it might be the implementation of a program known to reduce rates of a particular illness, tailored to the needs of a particular community.

But central guidance and rigorous evaluation are vital, to ensure that limited funds are spent wisely. The goal is to share lessons about how to reduce potentially preventable hospitalisations, and ultimately to enable people in some of the most disadvantaged parts of the country to lead healthier, more-productive lives.