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GENERAL PRACTICE: Antonio Giuffrida, Hugh Gravelle, and Martin Roland Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes BMJ 1999; 319: 94-98 [Abstract] [Full text]

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Hospital admission rates as a performance indicator

Peter Martin   (16 July 1999)

Hospital admission rates as a performance indicator 16 July 1999
Peter Martin Send response to journal: Re: Hospital admission rates as a performance indicator	Editor - The problems of using hospital admissions for chronic diseases as an indicator for general practice quality have recently been discussed in two articles (1,2) and an editorial (3). One of the main conclusions was that admission rates are influenced by factors outside the general practitioner's control, particularly those related to the patient population and to the hospital service. Clearly some method of adjusting for population differences would improve the validity of this indicator. However the fact that secondary care characteristics also have an important influence on hospital admission rates raises an interesting question. It seems reasonable to assume that high admission rates for chronic diseases caused by hospital factors reflect over-capacity, low admission thresholds, inadequate pre-admission assessment or consultants' interest in specific conditions. These factors influence mainly the appropriateness of the secondary care services offered to a particular population rather than the standard of care given after admission.The recent NHS-reforms place the responsibility for commissioning of secondary care on general practitioners. High quality commissioning should, amongst other things, ensure that secondary care is appropriate to the needs of the population. Reported experience from the total purchasing pilots in achieving objectives for hospital services seems to suggest this may be difficult (4) but it is nonetheless a responsibility associated with commissioning. The headline for the admission rate indicator is "Effective Delivery of Appropriate Healthcare" (5). Performance indicators should be measures of what the relevant decision makers can reasonably be held to account for (1). Primary care groups will be accountable for their dispositions within a unified budget. If I have understood the NHS-reforms correctly and provided the problem of variations in population characteristics can be allowed for, would not the admission rate for chronic diseases be an excellent indicator if used at primary care group level as it would indicate the combined results of the quality of primary care and the quality of commissioning of secondary care? This would require an extension of the rationale for the indicator (5). Its value as a performance indicator for primary care groups could increase over time as it becomes more reasonable to expect the groups to have a real influence on secondary care provision. Dr Peter Martin Senior Medical Adviser Primary Care Division Dept. of Primary Health Care and Social Services Oslo Municipal Executive Board Oslo, Norway References 1 Giuffrida A, Gravelle H, Roland M. Measuring quality of care with routine data: avoiding confusion between performance indicators and health outcomes. BMJ 1999;319:94-8. 2 Reid FDA, Cook DG, Majeed A. Explaining variation in hospital admission rates between general practices: cross sectional study. BMJ 1999;319:98- 103. 3 Jankowski R. What do hospital admission rates say about primary care? BMJ 1999;319:67-8. 4 Majeed A, Malcolm L. Unified budgets for primary care groups. BMJ 1999; 318: 772-6. 5 NHS Executive. Quality and performance in the NHS: High level performance indicators. http://www.doh.gov.uk/indicat/nhshlpi.htm 1999 (June):36. Conflict of interests: none