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NIHR Signal Annual health checks for people with intellectual disabilities reduce preventable emergency admissions

Published on 2 August 2016

doi: 10.3310/signal-000277

Annual health checks for people with intellectual disabilities in England, introduced in 2009, reduced emergency admissions for potentially preventable conditions, such as constipation or choking on food, by about a quarter. However they have not reduced overall emergency or elective admissions to hospital. The benefits were clearer for people with more severe and complex health needs.

An increasing proportion of the UK’s 1.5 million people with an intellectual disability live in the community, which makes the role of their GP important to their overall health. People with an intellectual disability often have associated health issues, such as heart problems and epilepsy. They are more likely to die earlier than the general population. The finding from this study should be seen in the context of increasing emergency admission rates for most conditions recently.

Annual health checks, introduced with extra funding as an enhanced service, are intended to improve the health of people with intellectual disabilities by identifying and treating health problems earlier, and improve links with GP practice staff. Uptake has been low with only half of eligible adults receiving health checks by 2012.

The encouraging preliminary findings should stimulate further research on the cost-effectiveness of health checks. Looking for the reasons why some practices achieved high uptake and low admission rates might also help decisions makers assess how widely these checks should be encouraged for this underserved population group.

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Why was this study needed?

Around 1.5 million people in the UK have an intellectual disability. The extent to which someone’s ability to function is affected by their intellectual disability varies, with some people able to live very independently whilst others require more support.

A recent NIHR-funded article found that people with intellectual disabilities in England are more likely to die young than people in the general population, and that more than a third of early deaths were potentially amendable to health care interventions. The NHS in England introduced annual health checks for people aged 14 and over with intellectual disabilities in 2009.

This NIHR funded study set out to investigate whether annual health checks had any impact on the number of hospital admissions for people with intellectual disabilities.

What did this study do?

This study analysed hospital admissions for people with an intellectual disability from across English GP practices. Emergency admissions, preventable emergency admissions and elective admissions were all looked at separately. Practices with high and low uptakes of health checks were compared. Practices that had seen 50% or more of their patients with intellectual disability were classified as having a high-uptake of health checks (126 practices) while those seeing less than 25% were classified as non-participating (95 practices). Also, the number of hospital admissions for individuals who had received a health check were compared to matched individuals admitted to hospital who had not received a health check.

This was not a trial, and practices were not randomised or matched. It took the opportunity presented by the introduction of the programme to observe and compare practices with low uptake with those who had higher uptake. It also looked at the reasons for admission for people with intellectual disability who had had health checks compared to those who had not. One limitation of the approach is that practices with a high-uptake had, on average, more adults with intellectual disability in their practice, and may therefore also be more likely to provide improved care for people with intellectual disability, possibly exaggerating any positive outcome.

What did it find?

  • There was no significant difference in overall emergency admissions amongst people with intellectual disabilities in GP practices with high-uptake compared to non-participating practices (incident rate ratio [IRR] 0.97, 95% confidence interval [CI] 0.78 to 1.19).
  • Emergency admissions for conditions requiring hospitalisation – such as constipation or inhalation of food – that are potentially preventable through better clinical management were lower in high-uptake practices compared to non-participating practices (IRR 0.74, 95% CI 0.58 to 0.95). These conditions are called “ambulatory care sensitive conditions”.
  • There was no difference in emergency admissions between people with intellectual disabilities who had or had not received a health check (IRR 0.96, 95% CI 0.87 to 1.07). There was also no difference in elective admissions.
  • There was a reduction in preventable (i.e. ambulatory care sensitive conditions) emergency admissions amongst people who received a health check compared to people who had not received a health check (IRR 0.82, 95% CI 0.69 to 0.99).

What does current guidance say on this issue?

NHS England introduced annual health checks for people with intellectual disabilities in 2009 as a Directed Enhanced Service in primary care. Health checks for people with intellectual disabilities are designed to improve their health by identifying and treating medical conditions early. This includes screening for health issues that are more common in people with intellectual disabilities and health promotion (such as healthy eating).

The Royal College of General Practitioners has produced guidelines for GPs carrying out health checks. It recommends that all health checks include an assessment of feeding, bowel and bladder function; assessment of behavioural disturbance and assessment of vision and hearing. There are also some syndrome-specific checks that GPs carry out for people with specific intellectual disabilities that are associated with physical health problems, such as Down’s syndrome.

What are the implications?

Although health checks did not affect overall hospital admissions, they did reduce emergency admissions for conditions that may be prevented through improved clinical management. Their impact was also greater for people with more severe and complex needs.

Increasing numbers of people with intellectual disabilities live in the community, rather than medical residential facilities, and therefore GPs are important in ensuring their health needs are met. Currently under 60% of GP practices offer annual health checks to people with intellectual disabilities. While these findings are encouraging, the observational nature of the study means that it is hard to split apart the effect of the health check from other factors.

Citation and Funding

Carey IM, Hosking FJ, Harris T, et al. Do health checks for adults with intellectual disability reduce emergency hospital admissions? Evaluation of a natural experiment. J Epidemiol Community Health. 2016. [Epub ahead of print].

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/64/154).

Bibliography

Hosking FJ, Carey IM, Shah SM, et al. Mortality among adults with intellectual disability in England: Comparisons with the general population. Am J Public Health. 2016;106(8):1483-90.

Mencap. What is a learning disability? London: Mencap; updated 2016.

NHS Choices. What is a learning disability? London: Department of Health; updated 2015.

NHS Choices. Learning disabilities: annual health checks. London: Department of Health; updated 2015.

RCGP. A step by step guide for GP practices: annual health checks for people with a learning disability. London: Royal College of General Practitioners; 2010.

Why was this study needed?

Around 1.5 million people in the UK have an intellectual disability. The extent to which someone’s ability to function is affected by their intellectual disability varies, with some people able to live very independently whilst others require more support.

A recent NIHR-funded article found that people with intellectual disabilities in England are more likely to die young than people in the general population, and that more than a third of early deaths were potentially amendable to health care interventions. The NHS in England introduced annual health checks for people aged 14 and over with intellectual disabilities in 2009.

This NIHR funded study set out to investigate whether annual health checks had any impact on the number of hospital admissions for people with intellectual disabilities.

What did this study do?

This study analysed hospital admissions for people with an intellectual disability from across English GP practices. Emergency admissions, preventable emergency admissions and elective admissions were all looked at separately. Practices with high and low uptakes of health checks were compared. Practices that had seen 50% or more of their patients with intellectual disability were classified as having a high-uptake of health checks (126 practices) while those seeing less than 25% were classified as non-participating (95 practices). Also, the number of hospital admissions for individuals who had received a health check were compared to matched individuals admitted to hospital who had not received a health check.

This was not a trial, and practices were not randomised or matched. It took the opportunity presented by the introduction of the programme to observe and compare practices with low uptake with those who had higher uptake. It also looked at the reasons for admission for people with intellectual disability who had had health checks compared to those who had not. One limitation of the approach is that practices with a high-uptake had, on average, more adults with intellectual disability in their practice, and may therefore also be more likely to provide improved care for people with intellectual disability, possibly exaggerating any positive outcome.

What did it find?

  • There was no significant difference in overall emergency admissions amongst people with intellectual disabilities in GP practices with high-uptake compared to non-participating practices (incident rate ratio [IRR] 0.97, 95% confidence interval [CI] 0.78 to 1.19).
  • Emergency admissions for conditions requiring hospitalisation – such as constipation or inhalation of food – that are potentially preventable through better clinical management were lower in high-uptake practices compared to non-participating practices (IRR 0.74, 95% CI 0.58 to 0.95). These conditions are called “ambulatory care sensitive conditions”.
  • There was no difference in emergency admissions between people with intellectual disabilities who had or had not received a health check (IRR 0.96, 95% CI 0.87 to 1.07). There was also no difference in elective admissions.
  • There was a reduction in preventable (i.e. ambulatory care sensitive conditions) emergency admissions amongst people who received a health check compared to people who had not received a health check (IRR 0.82, 95% CI 0.69 to 0.99).

What does current guidance say on this issue?

NHS England introduced annual health checks for people with intellectual disabilities in 2009 as a Directed Enhanced Service in primary care. Health checks for people with intellectual disabilities are designed to improve their health by identifying and treating medical conditions early. This includes screening for health issues that are more common in people with intellectual disabilities and health promotion (such as healthy eating).

The Royal College of General Practitioners has produced guidelines for GPs carrying out health checks. It recommends that all health checks include an assessment of feeding, bowel and bladder function; assessment of behavioural disturbance and assessment of vision and hearing. There are also some syndrome-specific checks that GPs carry out for people with specific intellectual disabilities that are associated with physical health problems, such as Down’s syndrome.

What are the implications?

Although health checks did not affect overall hospital admissions, they did reduce emergency admissions for conditions that may be prevented through improved clinical management. Their impact was also greater for people with more severe and complex needs.

Increasing numbers of people with intellectual disabilities live in the community, rather than medical residential facilities, and therefore GPs are important in ensuring their health needs are met. Currently under 60% of GP practices offer annual health checks to people with intellectual disabilities. While these findings are encouraging, the observational nature of the study means that it is hard to split apart the effect of the health check from other factors.

Citation and Funding

Carey IM, Hosking FJ, Harris T, et al. Do health checks for adults with intellectual disability reduce emergency hospital admissions? Evaluation of a natural experiment. J Epidemiol Community Health. 2016. [Epub ahead of print].

This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 12/64/154).

Bibliography

Hosking FJ, Carey IM, Shah SM, et al. Mortality among adults with intellectual disability in England: Comparisons with the general population. Am J Public Health. 2016;106(8):1483-90.

Mencap. What is a learning disability? London: Mencap; updated 2016.

NHS Choices. What is a learning disability? London: Department of Health; updated 2015.

NHS Choices. Learning disabilities: annual health checks. London: Department of Health; updated 2015.

RCGP. A step by step guide for GP practices: annual health checks for people with a learning disability. London: Royal College of General Practitioners; 2010.

Do health checks for adults with intellectual disability reduce emergency hospital admissions? Evaluation of a natural experiment

Published on 16 June 2016

Carey IM, Hosking FJ, Harris T, DeWilde S, Beighton C, Shah SM, Cook DG

Journal of Epidemiology & Community Health , 2016

BACKGROUND: Annual health checks for adults with intellectual disability (ID) have been incentivised by National Health Service (NHS) England since 2009, but it is unclear what impact they have had on important health outcomes such as emergency hospitalisation. METHODS: An evaluation of a 'natural experiment', incorporating practice and individual-level designs, to assess the effectiveness of health checks for adults with ID in reducing emergency hospital admissions using a large English primary care database. For practices, changes in admission rates for adults with ID between 2009-2010 and 2011-2012 were compared in 126 fully participating versus 68 non-participating practices. For individuals, changes in admission rates before and after the first health check for 7487 adults with ID were compared with 46 408 age-sex-practice matched controls. Incident rate ratios (IRRs) comparing changes in admission rates are presented for: all emergency, preventable emergency (for ambulatory care sensitive conditions (ACSCs)) and elective emergency. RESULTS: Practices with high health check participation showed no change in emergency admission rate among patients with ID over time compared with non-participating practices (IRR=0.97, 95% CI 0.78 to 1.19), but emergency admissions for ACSCs did fall (IRR=0.74, 0.58 to 0.95). Among individuals with ID, health checks had no effect on overall emergency admissions compared with controls (IRR=0.96, 0.87 to 1.07), although there was a relative reduction in emergency admissions for ACSCs (IRR=0.82, 0.69 to 0.99). Elective admissions showed no change with health checks in either analysis. CONCLUSIONS: Annual health checks in primary care for adults with ID did not alter overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.

Intellectual (or learning) disability and learning difficulty are sometimes wrongly used interchangeably.

Learning difficulties include conditions such as dyslexia, which may affect a person’s ability to learn and to understand but do not affect their overall intellectual abilities.

Intellectual (or learning) disabilities affect a person’s intellectual abilities and therefore their ability to learn new skills, understand complicated information and interact with others. People with intellectual disabilities require varying amounts of support, with some able to live very independent lives and others requiring 24-hour support with everyday living. This is dependent both on the severity of their intellectual disability, but also on any physical health problems they may have.

Intellectual disabilities have a range of causes, including the mother being seriously ill during pregnancy, birth complications, chromosomal abnormalities, inherited conditions or childhood brain injuries.

Expert commentary

The introduction annual health check for adults with intellectual disability has brought a number of health benefits to this population. While this study did not show that the introduction of these checks had any impact on either emergency or elective admissions, there was evidence to suggest that they reduced emergency admissions due to ambulatory care sensitive conditions - conditions where effective community care and case management may help prevent the need for hospital admission.

Dr Fabian Haut, Consultant Psychiatrist, NHS Tayside