Secondary Care Utilisation Research Articles

Access points to different levels of health care over 13 years. Utilization behaviour in a changing health care system. Results of a three-wave cross-sectional series in Austria.

Providing health care is a balancing act among human resources, financial pressures and system-intrinsic factors. Understanding the utilization behaviour of primary and secondary care facilities [general practitioners (GPs) vs. specialists, as well as in- and outpatient hospital care] is crucial for a country like Austria, which has free access to all levels of care. The aim of this study was to reassess access point consultations in relation to sociodemographic variables over time. The databases used for this cross-sectional analysis were the Austrian Health Interview Surveys 2006/07, 2014, and 2019, with sample sizes of 15 474, 15 770, and 15 461 persons, respectively. Analyses included patterns of utilization behaviour, multivariable logistic regression models, and diff-in-diff analyses highlighting differences between the observation periods. GP and secondary care consultations increased from 2014 to 2019. While there were fewer GP visits in 2014 than in 2006/07, GP consultation rates grew by 3.2% between 2014 and 2019. Secondary care utilization increased by 5.4%-8.2% between 2006/07 and 2019, with the highest growth in older and less-educated persons. Secondary-level utilization without prior GP visits decreased again in 2019 after peaking in 2014. Utilization of all access points increased over the entire observation period, especially regarding secondary-level care. Higher GP visit rates do not seem to result in a drop in secondary-level consultations. These results emphasize the coordinator role of primary care in ongoing structural health reforms in European countries, such as Austria.

Optimizing physician-encounter frequency for type 2 diabetes patients in primary care based on cardiovascular risk assessment: A target trial emulation study.

To investigate whether the physician-encounter interval for patients with type 2 diabetes (T2D) can be optimized from 2-3 to 4-6 months among those with a calculated 10-year cardiovascular disease (CVD) risk score of less than 20% without compromising their long-term outcomes. Using territory-wide public electronic medical records in Hong Kong, we emulated a target trial to compare the effectiveness of the physician-encounter intervals of 4-6 versus 2-3 months for T2D patients without prior CVDs and with a predicted risk for CVDs of less than 20% (i.e. those patients not in the high-risk category). Propensity score matching was used to emulate the randomization of participants at baseline, where 42 154 matched individuals were included for analysis. The marginal structural model was applied to estimate the hazard ratio (HR) for CVD incidence and all-cause mortality, the incidence rate ratio of secondary and tertiary care utilization, as well as the between-group differences in HbA1c, blood pressure and cholesterol levels. During a follow-up period of up to 12 (average: 5.1) years, there was no significantly increased risk of CVD in patients with physician-encounter intervals of 4-6 months compared with those patients with physician-encounter intervals of 2-3 months (HR [95% confidence interval {CI}]: 1.01 [0.90, 1.14]; standardized 10-year risk difference [95% CI]: -0.1% [-0.7%, 0.6%]), nor for all-cause mortality (HR: 1.00 [0.84, 1.20]; standardized 10-year risk difference: -0.1% [-0.5%, 0.3%]). Additionally, there was no observable difference in the utilization of secondary and tertiary care or key clinical parameters between these two follow-up frequencies. For T2D patients with a calculated 10-year CVD risk of less than 20%, the interval of regular physician encounters can be optimized from 2-3 to 4-6 months without compromising patients' long-term outcomes and saving substantial service resources in primary care.

Real-world study of the multimorbidity and health service utilisation among individuals with non-diabetic hyperglycemia and type 2 diabetes mellitus in North West London

IntroductionThe prevalence of non-diabetic hyperglycemia (NDH) and type 2 diabetes mellitus (T2DM) is increasing. While T2DM is recognised to be associated with multimorbidity and early mortality, people with NDH are...

Inequalities in emergency care use across transition from paediatric to adult care: a retrospective cohort study of young people with chronic kidney disease in England.

Sociodemographic inequalities in emergency secondary care usage were evident in this cohort across the transition period, independent of age, with some variation between admissions and A&E use, and evidence of effect modification by transfer. Such inequalities likely have multifactorial origin, but importantly, could represent differential meetings of care needs. • In chronic kidney disease (CKD), transfer from paediatric to adult healthcare is associated with declining health outcomes. • Known differences in CKD outcomes by sociodemographic factors have limited prior exploration in the context of transfer. • Population-level data was used to examine the impacts of transfer and sociodemographic factors on unplanned secondary care utilisation in CKD. • Healthcare utilisation trends may not reflect known CKD pathophysiology and there may be unexplored sociodemographic inequalities in the experiences of young people across transfer.

Impact on all-cause mortality of a case prediction and prevention intervention designed to reduce secondary care utilisation: findings from a randomised controlled trial

BackgroundHealth coaching services could help to reduce emergency healthcare utilisation for patients targeted proactively by a clinical prediction model (CPM) predicting patient likelihood of future hospitalisations. Such interventions are designed...

Reducing the burden of knee osteoarthritis through community pharmacy: Protocol for a randomised controlled trial of the Knee Care for Arthritis through Pharmacy Service.

Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio-economic wellbeing of those affected. Little community-based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Māori and non-Māori with knee OA in community pharmacy and providing co-ordinated, evidence- and community-based care may be a scalable, sustainable, equitable, effective and cost-effective approach to improve health and wellbeing. Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee-related physical function and pain (co-primary outcomes). Secondary aims assess impacts on health-related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Māori. A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12months for Māori and non-Māori who have knee OA. Participants will be recruited in community pharmacies. Knee-related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee-related pain will be measured using an 11-point numeric pain rating scale. Primary outcome analyses will be conducted on an intention-to-treat basis using linear mixed models. Parallel within-trial health economic analysis and process evaluation will also be conducted. Ethical approval was obtained from the Central Health and Ethics Committee (2022-EXP-11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants.

Ethnic variation in asthma healthcare utilisation and exacerbation: systematic review and meta-analysis.

Patients from ethnic minority groups (EMGs) frequently report poorer asthma outcomes; however, a broad synthesis summarising ethnic disparities is yet to be undertaken. What is the magnitude of ethnic disparities in asthma healthcare utilisation, exacerbations and mortality? MEDLINE, Embase and Web of Science databases were searched for studies reporting ethnic variation in asthma healthcare outcomes (primary care attendance, exacerbation, emergency department (ED) visits, hospitalisation, hospital readmission, ventilation/intubation and mortality) between White patients and those from EMGs. Estimates were displayed using forest plots and random-effects models were used to calculate pooled estimates. We conducted subgroup analyses to explore heterogeneity, including by specific ethnicity (Black, Hispanic, Asian and other). 65 studies, comprising 699 882 patients, were included. Most studies (92.3%) were conducted in the United States of America (USA). Patients from EMGs had evidence suggestive of lower levels of primary care attendance (OR 0.72, 95% CI 0.48-1.09), but substantially higher ED visits (OR 1.74, 95% CI 1.53-1.98), hospitalisations (OR 1.63, 95% CI 1.48-1.79) and ventilation/intubation (OR 2.67, 95% CI 1.65-4.31) when compared to White patients. In addition, we found evidence suggestive of increased hospital readmissions (OR 1.19, 95% CI 0.90-1.57) and exacerbation rates (OR 1.10, 95% CI 0.94-1.28) among EMGs. No eligible studies explored disparities in mortality. ED visits were much higher among Black and Hispanic patients, while Asian and other ethnicities had similar rates to White patients. EMGs had higher secondary care utilisation and exacerbations. Despite the global importance of this issue, the majority of studies were performed in the USA. Further research into the causes of these disparities, including whether these vary by specific ethnicity, is required to aid the design of effective interventions.

Primary Care Wound Clinics: A Qualitative Descriptive Study of Patient Experiences in Community Pharmacies.

The expansion of primary care wound services serves to alleviate secondary and tertiary care utilization. However, patient satisfaction is required to ensure service uptake. In recent years, various community pharmacies in Australia have begun to offer dedicated wound clinics; however, evaluations of patient experiences have yet to be conducted. Thus, the present study seeks to explore: (1) the experiences and satisfaction of patients who have received wound care consultations for their acute wounds in a community pharmacy setting; and (2) how current pharmacy-based wound services can be improved. Semi-structured individual interviews were conducted with patients across five pharmacy-based wound care clinics in Western Australia. Interviews were audio-recorded, transcribed verbatim, and imported into QSR NVivo 12 Plus. Interview transcripts were coded and thematically analyzed using the framework method. Twelve interviews were required to reach data saturation. Five key themes emerged: the accessibility of wound services, the comprehensiveness of wound care services, confidence in wound care consultants, the awareness and promotion of wound services, and the expansion of wound care services. Overall, participants were satisfied with the accessibility and comprehensiveness of pharmacy-based wound service delivery, trusted the health care providers, and wanted the service to be expanded. The reported patient satisfaction, confidence in the health care provider, and desire to expand the service suggests there is potential for the service to grow in Australia. Due to the growing costs of wound care globally, there is scope to further evaluate and expand wound care services in the primary care setting on an international level.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Care and Disease Management: Why Managed Care Organizations (MCOs) Need to have an Inclusive Approach to Patient Care

The health sector increasingly uses the terms "managed care" and "disease management," but few people understand them. Managed care refers to any health care system that pays for and provides treatment. Pressure to keep prices low has helped it flourish in the United States, and improved resource management is lowering costs. US managed care plans vary, but they share several traits. These include restricted doctor providers, secondary care access, selective contracting, financial incentives, quality monitoring, and utilization management. The NHS has all of these aspects, making it a united managed care system. Disease management coordinates resources across the health care system to treat patients throughout their illness. Business organizations have noticed that the NHS lacks a well-established system for disease management. Concerns regarding commercial engagement include the separation of basic medical services, the possibility of becoming a for-profit corporation, and the use of patient-based data. New guidelines may allow NHS disease control to increase.

Interventions developed to reduce secondary care utilisation in patients with type 2 diabetes mellitus: a narrative review.

To identify, describe and critically appraise the quality of studies of interventions developed to reduce the rate of secondary care utilisation and investigate interventions' impact on patients with type 2 diabetes mellitus (T2DM). Using a systematic approach, five databases were searched between 01 January 1995 and 01 February 2021 (MEDLINE, EMBASE, PsycINFO, CINAHL and Cochrane database). Inclusion criteria were studies (published in English) in adults with T2DM offered intervention(s) involving medicines/services/educational programmes in any country or setting, with investigated outcomes including the rate of hospital admission/re-admission/accident and emergency visits. Validated tools were used to assess the quality and accuracy of reporting the interventions. A narrative synthesis was used to frame the findings. A total of 4670 papers were identified, which yielded a final 53 studies after screening against the inclusion criteria. Identified interventions were complex interventions (n = 21) including at least two interventions (e.g. improving medication adherence and patient education), medication management (n = 15), patient education programmes (n = 8), lifestyle interventions (n = 5) and other interventions (n = 4; e.g. dental care). After assessing for quality and effectiveness of interventions, 15 studies remained; 7 were medication management interventions (e.g. use of insulin pen) and 8 were complex interventions (e.g. pharmaceutical care and telehealth systems). Complex interventions showed significant improvement in clinical outcomes and reduction in secondary care utilisation. This narrative review identified potential elements of an effective complex intervention to reduce healthcare utilisation in patients with T2DM. These results could inform the development of interventions to be tested for feasibility, before piloting to assess for outcomes that improve diabetic care, reduce diabetes-related complications and minimise healthcare utilisation.

Does post-operative neuropathic pain after shoulder surgery affect secondary health care utilisation? A service evaluation

Purpose: Neuropathic pain has been recognised after shoulder surgery; neuropathic pain has been associated with poor outcomes after surgery. However, the impact of neuropathic pain on health care demand is not understood. The aim of this study is to identify the impact of pain of probable neuropathic origin on health care utilisation within our Trust.

Socioeconomic disparities in asthma health care utilization, exacerbations, and mortality: A systematic review and meta-analysis

Prior studies investigating the effect of socioeconomic status (SES) on asthma health care outcomes have been heterogeneous in the populations studied and methodologies used. We sought to systematically synthesize evidence investigating the impact of SES on asthma health care utilization, exacerbations, and mortality. We searched Embase, Medline, and Web of Science for studies reporting differences in primary care attendance, exacerbations, emergency department attendance, hospitalization, ventilation/intubation, readmission, and asthma mortality by SES. Study quality was assessed using the Newcastle Ottawa Scale, and meta-analyses were conducted using random-effects models. We conducted several prespecified subgroup analyses, including by health care system (insurance based vs universal government funded) and time period (before vs after 2010). A total of 61 studies, comprising 1,145,704 patients, were included. Lower SES was consistently associated with increased secondary health care utilization including emergency department attendance (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), hospitalization (OR, 1.63; 95% CI, 1.34-1.99), and readmission (OR, 1.31; 95% CI, 1.19-1.44). Substantial associations were also found between SES and ventilation/intubation (OR, 1.76; 95% CI, 1.13-2.73), although there was no association with primary care attendances (OR, 0.79; 95% CI, 0.51-1.24). We found evidence of borderline significance for increased exacerbations (OR, 1.18; 95% CI, 0.98-1.42) and mortality (OR, 1.12; 95% CI, 0.92-1.37) among more deprived groups. There was no convincing evidence that disparities were associated with country-level health care funding models or that disparities have narrowed over time. Patients with a lower SES have substantially increased secondary care health care utilization. We found evidence suggestive of increased exacerbations and mortality risk, although CIs were wide. These disparities have been consistently reported worldwide, including within countries offering universally funded health care systems. CRD42020173544.

Patterns and costs of hospital-based cancer care in the last year of life: A national data linkage study in England.

e18769 Background: Delivery of high quality cancer care is associated with rising costs, both in earlier stages of the illness trajectory and at the end of life. A significant portion of the costs and health care utilisation occurs in the last year of life. Most publications to date have focused on costs in hospital. Little is known about the costs of care for cancer patients across the entire health service. The aim was to examine primary, secondary and acute health care utilisation and cost in the last 12 months of life and how these differ by cancer diagnosis and other patient characteristics among decedent patients aged 60 and over. Methods: We conducted a retrospective cohort study of people aged 60 years and over (N=26,077) who died in England between 2010 and 2017. We used routinely collected and linked data from primary care (Clinical Practice Research Datalink (CPRD) secondary and acute care, (Hospital Episode Statistics (HES), and death data (Office for National Statistics (ONS)). This provided a nationally representative sample of the English population. We analysed of healthcare utilisation and resource use amongst decedents by gender, primary cause of death, age, geography, socio-economic status and comorbidities. Results: Overall, 90.2 % of the cancer decedents were admitted in the hospital at least once in the last 12 months of life. About 50% of patients we admitted to hospital in the last month of life with 37.6 being admitted to the hospital more than once in the last month of life. The health care utilisation and costs increased sharply in the last month of life. life. The mean number of hospital admissions in the last year of life was 3.7 (SD, 5.8). Those dying of haematological cancers (N=2093) had highest number of hospital admissions (mean:7.2, SD:10.8) and longer average hospital stay (mean:36.7, SD:33.0) (mean:12.0, SD:14.4). Use of outpatient services was highest in the group dying of haematological cancers (mean:12.0, SD:14.4) whereas those dying of prostate cancer (N= 2197) had higher number of emergency (mean:2.0, SD: 1.9) and GP visits (mean:30.8, SD: 20.7). Healthcare costs were highest among haematological cancers and lowest among those dying of breast cancer. Proximity to death and comorbidities were the main contributors of end-of-life care health care utilisation and costs. Conclusions: This study uses large linked datasets (linked to the whole spectrum of hospital episode statistics) providing a comprehensive picture of healthcare services accessed by cancer patients at end of life in England. There is significant variation in use and cost of care for cancer patients in the last year and month of life. Further analysis of variation according to hospice, palliative, and social care service provision may identify strategies to address this variation.

The employment and mental health impact of integrated Improving Access to Psychological Therapies: Evidence on secondary health care utilization from a pragmatic trial in three English counties.

Patients with a combination of long-term physical health problems can face barriers in obtaining appropriate treatment for co-existing mental health problems. This paper evaluates the impact of integrating the improving access to psychological therapies services (IAPT) model with services addressing physical health problems. We ask whether such services can reduce secondary health care utilization costs and improve the employment prospects of those so affected. We used a stepped-wedge design of two cohorts of a total of 1,096 patients with depression and/or anxiety and comorbid long-term physical health conditions from three counties within the Thames Valley from March to August 2017. Panels were balanced. Difference-in-difference models were employed in an intention-to-treat analysis. The new Integrated-IAPT was associated with a decrease of 6.15 (95% CI: -6.84 to -5.45) [4.83 (95% CI: -5.47 to -4.19]) points in the Patient Health Questionnaire-9 [generalized anxiety disorder-7] and £360 (95% CI: -£559 to -£162) in terms of secondary health care utilization costs per person in the first three months of treatment. The Integrated-IAPT was also associated with an 8.44% (95% CI: 1.93% to 14.9%) increased probability that those who were unemployed transitioned to employment. Mental health treatment in care model with Integrated-IAPT seems to have significantly reduced secondary health care utilization costs among persons with long-term physical health conditions and increased their probability of employment.

Functional neurological disorders presenting as emergencies to secondary care.

Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care. We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization. One hundred sixty-two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3-year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2-4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas. FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.

Variations in Secondary Health Resource Utilization Post Clozapine Initiation

This study looked at secondary care utilization metrics as an effectiveness indicator of Clozapine initiation in 77 patients over the following year compared to the year prior to initiation. It was found that there was a marginal drop in psychiatric bed utilization, alongside reduced crisis team use. Medical and psychiatric outpatient use increased, as did physical health interventions. Overall, compared with costs over the year preceding Clozapine initiation, an estimated saving per patient of £3,867 ($5,065) was achieved.

Frailty and healthcare utilisation across care settings among community-dwelling older adults in Singapore

BackgroundFrailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation in different care settings among community-dwelling older adults in Singapore.MethodsData from a population health survey among community-dwelling adults were linked with an administrative database to retrieve data of healthcare utilisation (including government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations) occurred during a six-month look-back period and six-month post-baseline respectively. Baseline frailty status was measured using the five-item FRAIL scale, which was categorised into three groups: robust (0), pre-frail (1–2), and frail (3–5). Negative binomial regression was applied to examine the association between frailty with respective healthcare utilisation (dependent variables), controlling for other confounding variables.ResultsIn our sample of 701 older adults, 64.8% were of robust health, 27.7% were pre-frail, and 7.6% were frail. Compared to the robust group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2–6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1–8.1), day surgery attendances (IRR: 6.4, 95%CI: 1.3–30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1–21.1) in the six-month period prior to the baseline and in subsequent 6 months (IRR: 3.3, 95%CI: 1.6–7.1; 6.4, 2.4–17.2; 5.8, 1.3–25.8; 13.1, 4.9–35.0; respectively), controlling for covariates.ConclusionsFrailty was positively associated with the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations occurred during 6 months prior to and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have potential effect on delaying secondary and tertiary care utilisation.

Intersectional equity in health care: assessing complex inequities in primary and secondary care utilization by gender and education in northern Sweden

BackgroundKnowledge remains scarce about inequities in health care utilization between groups defined, not only by single, but by multiple and intersecting social categories. This study aims to estimate intersectional horizontal inequities in health care utilization by gender and educational level in Northern Sweden, applying a novel methodological approach.MethodsData on participants (N = 22,997) aged 16–84 years from Northern Sweden came from the 2014 Health on Equal Terms cross sectional survey. Primary (general practitioner) and secondary (specialist doctor) health care utilization and health care needs indicators were self-reported, and sociodemographic information came from registers. Four intersectional categories representing high and low educated men, and high and low educated women, were created, to estimate intersectional (joint, referent, and excess) inequalities, and needs-adjusted horizontal inequities in utilization.ResultsJoint inequalities in primary care were large; 8.20 percentage points difference (95%CI: 6.40–9.99) higher utilization among low-educated women than high-educated men. Only the gender referent inequity remained after needs adjustment, with high- (but not low-) educated women utilizing care more frequently than high-educated men (3.66 percentage points difference (95%CI: 2.67–5.25)). In contrast, inequalities in specialist visits were dominated by referent educational inequalities, (5.69 percentage points difference (95%CI: 2.56–6.19), but with no significant horizontal inequity – by gender, education, or their combination – remaining after needs adjustment.ConclusionThis study suggests a complex interaction of gender and educational inequities in access to care in Northern Sweden, with horizontal equity observable for secondary but not primary care. The study thereby illustrates the unique knowledge gained from an intersectional perspective to equity in health care.

Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study

BackgroundCommunity hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital ward performance.Objectives(1) To measure the relative performance of community hospital wards (studies 1 and 2); (2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); (3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); (4) to investigate the impact of community hospital wards on secondary care use (study 5); and (5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5).MethodsStudy 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward costs. Study 2 – a national postal survey was developed to collect data from a larger sample of community hospitals. Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. Study 4 – a web-based interactive toolkit was developed by integrating the econometrics (study 1) and case study (study 3) findings. Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care.ResultsCommunity hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved (price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/(accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions.LimitationsThe econometric analyses were based on cross-sectional data and were also limited by missing data. The low response rate to our national survey means that we cannot extrapolate reliably from our community hospital sample.ConclusionsThe results suggest that significant community hospital ward savings may be realised by improving modifiable performance factors that might be augmented further by economies of scale.Future workHow less efficient hospitals might reduce costs and sustain quality requires further research.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 1. See the NIHR Journals Library website for further project information.