About this evaluation and analysis

This evaluation was conducted by the Improvement Analytics Unit – a partnership between the Health Foundation and NHS England that aims to provide local teams with robust information on the impact of initiatives to improve care, in order to inform ongoing improvement efforts. Analysis was conducted according to a statistical analysis protocol (SAP), which was subject to independent academic peer reviews and shared with the vanguard before analysis began.

We examined the effect of the enhanced support on new residents of 28 of the 29 nursing and residential care homes in Sutton. The analysis focused on people aged 65 years or over who moved into one of these care homes between January 2016 and April 2017, referred to hereafter as ‘Sutton residents in the study’. This period overlaps with the implementation of the vanguard, but not all interventions were implemented throughout the entirety of the period we studied, and those that were implemented were not in place for all care homes. For example, health and wellbeing rounds and link nurses were run for nine months during the study period at approximately one third of nursing care homes and one third of residential care homes (see Table 1).

We examined whether the enhanced support affected the hospital use of care home residents, including the number of A&E attendances and emergency hospital admissions for clinical conditions that were considered to be potentially avoidable. The use of hospital care by Sutton residents in the study was compared with a ‘control’ group of individuals, matched on a range of factors as outlined in the ‘Selecting the comparison group’ section on page 9. Both groups were followed up for as long as possible after admission to a care home. This analysis is based on data from January 2016 to April 2017, so the follow-up period varied between a minimum of 1 month and maximum of 15 months.

Analyses were also carried out to ascertain the effect on hospital use for subgroups of care home residents based on:

  • care home type – nursing or residential (due to known differences in the type and intensity of initiatives implemented in each type of home)
  • timing of entry to a care home – early or late in the study period (due to differences in implementation and ‘bedding in’ levels of the enhanced support over the study period).

Data used in the analysis

The Improvement Analytics Unit has access to pseudonymised data from the Secondary Uses Service (SUS) – a national, person-level database that is closely related to the widely-used Hospital Episode Statistics (HES). SUS data contains information on A&E attendances, inpatient admissions and outpatient appointments that are funded by the NHS in England, but unfortunately it does not record accurately whether an individual resides in a care home. Therefore, the unit needed a data set containing information on the residents of care homes, and a method of linking that data to SUS data.

This was assembled by the Arden & Greater East Midlands Data Services for Commissioners Regional Office (Arden & GEM DSCRO), the National Commissioning Data Repository in NHS England and the Improvement Analytics Unit. Care home residents were identified using a combination of monthly care home registry data published by the Care Quality Commission (CQC) and monthly extracts from the National Health Applications and Infrastructure Services (NHAIS) database, which contains a list of individuals registered at each general practice in England, including their residential address and NHS number.

The linked care home and hospital data were analysed by the Improvement Analytics Unit within an accredited secure data environment based at the Health Foundation. At no point did we have access to identifiable data. Throughout, the minimum amount of data was used.

Identifying the Sutton residents in the study

The study focused on individuals residing in a nursing or residential care home who fulfilled the following criteria:

  • moved into a Sutton care home between 17 January 2016 (ie two months after November 2015, which is when the first batch of interventions was implemented) and 16 April 2017
  • were not previously resident in a care home in the two years prior to their move-in date
  • were aged 65 years and over
  • experienced a hospital admission within the three years preceding entry to the care home (to ensure information on health conditions was available to inform the selection of an appropriate comparison group).

The evaluation only included nursing and residential care homes under the remit of Sutton CCG (ie having residents registered with a Sutton CCG GP) that were open between 17 January 2016 and 16 April 2016, to ensure a minimum period of care home activity within the study of one year. Care homes registered as catering for other age groups and with other specialties other than the frail, elderly care home population were excluded.

The final sample comprised 297 residents from 17 nursing and 11 residential care homes falling under the remit of Sutton CCG and participating in the enhanced support programme.

Selecting the comparison group

To evaluate the impact of the vanguard's enhanced support, it was necessary to form a comparison group of care home residents who were as similar as possible to the Sutton residents in the study. The process of forming the control group of care home residents is illustrated in Figure 1.

Control group residents were selected from areas that, before vanguard enhanced support was introduced in Sutton, had similar demographic and socioeconomic characteristics and emergency admission rates to Sutton.

Rates of hospital admission in the Sutton CCG before the enhanced support was introduced were slightly below the national average (944 emergency admissions for every 10,000 Sutton residents vs 1,034 for England as a whole in 2014/15)., The seven areas ultimately found to be most similar to Sutton CCG according to the above criteria were: Bexley CCG, Dartford, Gravesham and Swanley CCG, Leeds North CCG, Greater Huddersfield CCG, Bromley CCG, Havering CCG and North East Hampshire and Farnham CCG. The average emergency admission rate across these control areas was 970/10,000 residents, which is more in line with the rate observed for Sutton CCG relative to the national figure.,

While some of these areas may have been implementing changes to improve care for people living in care homes, to the best of our knowledge none were offering area-wide interventions targeted at care home residents of a scale and scope similar to Sutton’s enhanced support during the period concerned. Furthermore, since the control group comprised care home residents from multiple areas, the potential of each reviewed area to introduce significant bias was limited.

The same inclusion and exclusion criteria used to select Sutton residents in the study were also applied to care home residents in the selected comparable areas, giving a pool of potential controls consisting of 2,382 people from 194 care homes in the seven comparable areas. From these 2,382 residents, a matched control group was identified that was similar to the Sutton residents in the study on the following characteristics:

  • at care home level: the number of beds in the care home; whether the care home was registered with the CQC as a nursing or residential home; whether the care home was registered as caring for additional population groups in addition to older people; whether the care home was in a rural or urban setting; and the socioeconomic deprivation level of the local area
  • at residents’ level: age; gender; ethnicity; number and type of health conditions associated with frailty; diagnoses in the three years before introduction of the enhanced support predictive of emergency hospital readmissions (eg chronic pulmonary disease and congestive heart failure) or mortality (Charlson index); and numbers of emergency admissions, potentially avoidable emergency admissions, A&E attendances, elective admissions, hospitalisations due to falls and significant fractures, hospitalisations due to UTIs, hospitalisations due to venous thromboembolisms (VTEs) and hospital bed days in the two years prior to the start of the enhanced support.

When selecting controls, we did not use data on events that occurred following the admission to the care home, since this could have biased our findings. However, we checked that our final matched control group had a similar mortality rate to the Sutton residents, and that residents in the two groups spent a similar amount of time in our study.

We paired residents in nursing homes in Sutton with matched control individuals living in nursing homes in the comparable areas, and likewise residents in residential homes with matched controls living in residential homes. One matched control group resident was selected for each Sutton resident, yielding a sample of 297 residents from 97 care homes in the control group. A closer inspection of the selected control residents led to discarding an individual from the analysis because they were an outlier in terms of their hospital utilisation.

Figure 1: The process of forming the control group of care home residents

Comparisons between the Sutton residents and the matched comparison group were made using multivariable regression analysis. The regression models adjusted for the differences that remained after matching between the two groups in prior hospital use and other observed baseline characteristics such as age distribution, seasonality and number and type of comorbidities. Matching and regression generally perform better in combination than separately. The regression models produced a ‘best estimate’ of the relative difference in the examined hospital utilisation outcome between the Sutton residents and the matched comparison group, together with a 95% confidence interval.

The same procedure was followed in subgroup analyses, for which the total population was divided into groups according to care home type (residential or nursing), and time of entry to a care home (‘early entrants’ or ‘late entrants’). Late entrants were defined as those who moved to a care home in Sutton or a comparable CCG on or after 31 August 2016 (ie midway into the follow-up period), while those who moved before this date and had not stayed in the study for longer than 7.5 months were considered early entrants.

Outcome measures

Once a matched group of control care home residents was satisfactorily formed (see the section on page 13 'Characteristics of the Sutton residents in the study and the matched comparison group were broadly similar' for details), the Improvement Analytics Unit proceeded with comparing hospital activity between the two groups. For this purpose, the following seven outcomes were analysed:

  • A&E attendances
  • emergency admissions
  • the subset of ‘potentially avoidable’ emergency admissions, based on a list of conditions considered to be manageable in community settings or preventable through good quality care (see Box 1)
  • hospital bed days
  • admissions with a UTI as the principal diagnosis
  • outpatient appointments
  • proportion of deaths occurring outside hospital (taken as an indicator of successful end-of-life planning).

Box 1: Conditions for which we considered emergency admissions to be potentially avoidable

The analysis included conditions that are often manageable, treatable or preventable in community settings without the need to go to hospital, as well as those that may be caused by poor care or neglect. These were:

  • acute lower respiratory tract infections, such as acute bronchitis
  • chronic lower respiratory tract infections, such as emphysema
  • diabetes
  • food and drink issues, such as abnormal weight loss and poor intake of food and water, possibly due to neglect
  • fractures and sprains
  • intestinal infections
  • pneumonia
  • pneumonitis (inflammation of lung tissue) caused by inhaled food or liquid
  • pressure sores
  • UTIs.

To calculate the number of potentially avoidable emergency admissions, we counted hospital admissions with one of these conditions listed as the primary diagnosis for an admission to hospital. Note, however, that this list of conditions was originally intended to be applied to the general population aged 65 or over, rather than to care home residents. Note also that sometimes individuals will still need to be admitted to hospital for these conditions independently of the availability of suitable out-of-hospital care (as is perhaps the case with individuals suffering from multiple co-morbidities) and regardless of the quality of the care offered in the care home. The metric is therefore not perfect, but we would expect the enhanced support to show greater impact on reducing the risk of hospital admission for these conditions than for others.

Hospital activity was measured for the period during which individuals were resident in care homes, counted from the month they moved into the care home to the month that they died or left the care home (or April 2017, if sooner). This analysis is based on data from 17 January 2016 until 16 April 2017. Individuals were followed up for their whole duration of stay in the care home since their admission, with a minimum follow up period of 1 month and maximum of 15 months.

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