Director of Public Health Annual Report 2012 [pdf] - Stoke-on-Trent ...

EVIDENCE: Research
Research focuses on the complex mix <strong>of</strong> factors that influence the development <strong>of</strong> long-term
conditions as well as finding better ways to diagnose and treat. It is equally important that
research occurs locally, taking into account local cultural, social and healthcare settings.
Local research, as illustrated in the case study, reviewed the impact <strong>of</strong> ‘pairs’ <strong>of</strong> LTCs on
hospital admissions 30 .
Case
Study
Local Research
Keele University is developing a risk stratification tool to identify ‘Frail Elderly’ people
using information from primary care. It aims to allow clinical staff to identify and
proactively manage ‘Frail Elderly’ patients, avoiding some inappropriate uses <strong>of</strong> urgent
care services. People are defined as ‘Frail’ when they have an increased likelihood for
death, disability, dependency, falls, and need for long-term care. Admission prediction
and <strong>of</strong>fering preventive care can improve the health status <strong>of</strong> these high-risk patients.
This may also reduce unplanned admissions making overall savings for the NHS. The
tool will initially be applied to patients in nursing and care homes.
Mosaic pr<strong>of</strong>iles <strong>of</strong> groups are also used to understand differing levels <strong>of</strong> hospital
admissions and costs among people who have some LTCs. A local study looking at
people with ‘pairs’ <strong>of</strong> LTCs, found that some combinations <strong>of</strong> LTCs had a higher
likelihood <strong>of</strong> hospital admission that others. Over one in three (67%) <strong>of</strong> individuals with
both chronic heart failure and chronic kidney disease had at least one A&E episode;
four in five (80%) <strong>of</strong> this group had a hospital admission. In comparison, over one in
three (37%) individuals with hypertension and diabetes had at least one A&E episode;
over two in five (44%) a hospital admission. The study also found higher costs
associated with some LTC combinations.
More recent research 31 focusing on primary care suggests the need to shift the focus from
individual disease quality frameworks, particularly for patients with multimorbidity, to those
using a range <strong>of</strong> tools to integrate and prioritise care pathways. The different evidencebased
elements that contribute to the overall identification, management and improvement in
care <strong>of</strong> people with long-term conditions naturally work most effectively when combined in a
seamless model <strong>of</strong> care such as the one in figure 15.
Query
What is Mosaic
Mosaic is a classification system that uses individual postcode level data to create a
picture <strong>of</strong> local neighbourhoods in regards to socioeconomic, lifestyle, cultural and
behavioural characteristics. It is designed to describe different types <strong>of</strong> people living in
particular areas, what their specific needs are and how best to engage them.
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