Patterns of emergency admissions for ambulatory care sensitive conditions::a spatial cross-sectional analysis of observational data

Objectives: To examine the spatial and temporal patterns of English general practices’ emergency admissions for Ambulatory Care Sensitive Conditions (ACSC). Design: Observational study of annual hospital admission data for ACSC emergency admissions at general practice level for all practices in England 2004 to 2017. Participants: All patients with an emergency admission to a National Health Service (NHS) hospital in England who were registered with an English GP practice. Main outcome measure: Practice level age and gender indirectly standardised ratios (ISARs) for emergency admissions for ACSC. Results: In 2017 41.8% of the total variation in ISARs across practices was between the 207 Clinical Commissioning Groups (the administrative unit for general practices) and 58.2% was across practices within CCGs. ACSC ISARs increased by 4.7% between 2004 and 2017 while those for conditions incentivised by the Quality and Outcomes Framework fell by 20.02%. Practice ISARs are persistent: practices with high rates in 2004 also had high rates in 2017. Standardising by deprivation as well as age and gender reduced the coefficient of variation of practice ISARs in 2017 by 22% Conclusions: There is persistent spatial pattern of emergency admissions for ACSC across England both within and across CCGs. We illustrate the reduction in ACSC emergency admissions across the study period for conditions incentivised by the QOF but find that this was not accompanied by a reduction in variation in these admissions across practices. The observed spatial pattern persists when admission rates are standardised by deprivation. The persistence of spatial clusters of high emergency admissions for ACSC within and across CCG boundaries suggests that policies to reduce potentially unwarranted variation should be targeted at practice level.