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Reconfiguration of emergency and urgent care systems in Ireland from 2006: analysis of quantitative performance indicators at a population level
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Date
2019
Authors
Lynch, Brenda
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University College Cork
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Abstract
Background: Since the mid-2000s, the regional emergency and urgent care systems in Ireland have experienced a period of reconfiguration, with some regions undergoing more significant changes than others. Reasons for these changes include improved safety, efficiency and the pursuit of better outcomes. However, analysis of the impact of these changes at a population level has been under-investigated. Aims and objectives: The main aim of this thesis is to examine the impact of emergency and urgent care system reconfiguration on regional health system performance using quantitative indicators (structure, process and outcome) at a population level. This thesis has three objectives: 1. To investigate the impact of changes to emergency department (ED) services in smaller hospitals on the remaining EDs within regional emergency and urgent care systems; 2. To investigate the regional variation in ‘potentially avoidable’ emergency admissions and identify the drivers of those admissions within regional emergency and urgent care systems; 3. To determine if the case fatality ratios (CFRs) for emergency conditions have improved in line with system reconfiguration carried out at a regional level. Structure and methods: Chapter 2 provides an overview of contextual geographic details such as the degree of regional rurality, deprivation, and differences in demographics and health. Chapter 3 provides an overview of the Irish health system, including the provision of emergency and urgent care services. A summary of the most significant health policy, clinical programme and reconfiguration reports published in Ireland since 2006 is also provided. In Chapter 4 details of frameworks for assessing system performance, used in conjunction with key performance indicators (KPIs), are explored. Ultimately, the Donabedian framework was selected as the most appropriate to investigate the regional changes to emergency and urgent care system performance. Indicators associated with the domains structure, process and outcome were identified. The statistical methods used in each study are also outlined within this chapter. Under the domain of structure, a time-series analysis is used in Chapter 5 to investigate changes to ED services and the subsequent impact to the ED trolley numbers within regional hospitals between 2005-2015. To investigate the domain of process, Chapter 6 studies the population and health system factors which influence ‘potentially avoidable’ emergency admissions at a regional level. This is achieved by conducting a cross-sectional analysis of identified factors using negative binomial regression. The final study in Chapter 7 addresses the domain of outcome by providing a longitudinal investigation of trends in CFRs for serious emergency conditions over the period 2002-2014 using joinpoint analysis. In the final chapter, Chapter 8, a discussion of the key findings, strengths and limitations of the thesis is provided. Recommendations for future research are also outlined. Key findings: Regional variations were seen across each framework domain and performance indicator. Chapter 5 identifies three regions where the immediate impact of ED reconfiguration is either non-significant or associated with a short-term shock to observed ED trolley numbers. This shock was followed by convergence with the pre-reconfiguration trend over the 12-months post ED reconfiguration. Only one region, the North-East, saw a longer term change in the post-reconfiguration trend following changes to the second ED in the region. In Chapter 6, differences were found in the age-adjusted rates of ‘potentially avoidable’ emergency admissions across regions. The pattern of higher rates of emergency admissions was not consistent across those regions that had, or had not, undertaken significant emergency and urgent care system reconfiguration. The main findings of the study suggest that deprivation is the primary contributor to the variation seen in results across regions. Other factors found to have an impact were the level of short-term lengths of stay in hospital and the rate of private health insurance among the regional populations. In Chapter 7, significant improvements in CFRs were found for the main emergency conditions of stroke and acute myocardial infarction and cardiac arrest (AMI and CA) at a national level between 2002 and 2014, with the rate of improvement slowing from 2007 for stroke. However, the study was unable to attribute improvements seen at a regional level to the degree of reconfiguration within the emergency and urgent care system. Conclusions: This thesis adds to the evidence regarding the impact of the reconfiguration of emergency and urgent care systems in Ireland on regional populations. The degree of system reconfiguration varied across regions. Numerous other policies, clinical programmes, financial restrictions, changes to staff resources and hospital beds also occurred simultaneously. Ultimately, this research was unable to find a consistent pattern in performance indicators across regions which underwent significant system reconfiguration, meaning it is not possible to attribute indicator results definitively to reconfiguration measures.
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Keywords
Reconfiguration , Emergency medicine , Regional
Citation
Lynch, B. 2019. Reconfiguration of emergency and urgent care systems in Ireland from 2006: analysis of quantitative performance indicators at a population level. PhD Thesis, University College Cork.