title: Variation in avoidable emergency admissions: multiple case studies of emergency and urgent care systems.
abstract: OBJECTIVE
  To identify factors affecting variation in avoidable emergency admissions that are not usually identified in statistical regression.
  
  
  METHODS
  As part of an ethnographic residual analysis, we compared six emergency and urgent care systems in England, interviewing 82 commissioners and providers of key emergency and urgent care services.
  
  
  RESULTS
  There was variation between the six cases in how interviewees described three parts of their emergency and urgent care systems. First, interviewees' descriptions revealed variation in the availability of services before patients decided to attend emergency departments. Poor availability of general practice out of hours services in some of the cases reportedly made attendance at emergency departments the easier option for patients. Second, there was variation in how interviewees described patients being dealt with during their emergency department visit in terms of availability of senior review by specialists and in coding practices when patients were at risk of breaching the NHS's 4-hour waiting time target. Third, there was variability in services described as facilitating discharge home from emergency departments. In some cases, emergency department staff described dealing with multiple agencies in multiple localities outside the hospital, making admission the easier option. In other cases, proactive multidisciplinary rapid assessment teams were described as available to avoid admissions. Perceptions of resources available out of hours and the extent of integration between different health services, and between health and social services, also differed by case.
  
  
  CONCLUSIONS
  This comparative case study approach identified further factors that may affect avoidable emergency admissions. Initiatives to improve GP out of hours services, make coding more accurately reflect patient experience, increase senior review in emergency departments, offer proactive multidisciplinary admission avoidance teams, improve the availability of out of hours care in the wider emergency and urgent care system, and increase service integration may reduce avoidable admissions. Evaluation of such initiatives would be necessary before wide-scale adoption.
authors.affiliation: Professor of Health Services Research, School of Health and Related Research, University of Sheffield, UK a.ocathain@sheffield.ac.uk.
authors.forename: Alicia
authors.initials: A
authors.lastname: O'Cathain
authors.affiliation: Research Fellow, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Emma
authors.initials: E
authors.lastname: Knowles
authors.affiliation: Senior Research Fellow, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Janette
authors.initials: J
authors.lastname: Turner
authors.affiliation: Chair of Sheffield Emergency Care Forum, Sheffield, UK.
authors.forename: Enid
authors.initials: E
authors.lastname: Hirst
authors.affiliation: Professor of Emergency Medicine, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Steve
authors.initials: S
authors.lastname: Goodacre
authors.affiliation: Professor of Health Services Research, School of Health and Related Research, University of Sheffield, UK.
authors.forename: Jon
authors.initials: J
authors.lastname: Nicholl
keywords: emergency medical services; hospital admissions; urgent care