Dr Heidi Muenchberger

Muenchberger H, Kendall E. (2010) Predictors of preventable hospitalisation in chronic disease: priorities for change’. Journal of Public Health Policy, 31, 150—163.

Interviewer: Michael Bouwman (MB)

Interviewee: Heidi Muenchberger (HM)

MB: Introducing Dr Heidi Muenchberger, Senior Research Fellow, Centre for Population and Community Health, School of Human Services and Social Work, Griffith University, Australia. I’m speaking with Heidi about her article co-authored with Elizabeth Kendall, entitled, ‘Predictors of Preventable Hospitalisation in Chronic Disease: Priorities for Change’, published in the ‘Journal of Public Health Policy’. Your research paper explores the predictors of preventable hospital admissions in chronic diseases, could you provide a brief overview of your aim and methodology for exploring this topic?

HM: Sure, I think first of all I’d like to clarify the term ‘preventable admission’. What that actually means is people with chronic conditions who could otherwise be treated in the community, so that is by GP or health services who are best placed to care for them rather than going to an emergency department to a hospital to be managed under crisis care when that condition flares up.

MB: Right.

HM: And what it means is that there’s quite significant pressure on hospitals to manage this increasing crisis care whilst doing their normal work anyway. So the time has come for us to really think through how we treat people with chronic conditions better in the community to prevent them going to hospital for this crisis management. So that’s the reason why we undertook this study, we also wanted to really clarify what were the key issues at stake and what government and policy makers really had to consider in developing a better way forward. So our aim was to really take an inclusive approach to that and certainly recognise the social determinants that influence how these treatable conditions could indeed be best managed in the community. We also wanted to take the view that it was necessary to look at the factors that were most modifiable, so what could be enacted upon in the immediate term and although factors like age and gender are important certainly, there’s nothing that can be done to change that fact. We did want an action plan for the government and policy makers to be able to adopt.

MB: Okay.

HM: In terms of the methodology we undertook a systematic search of the literature using combined search techniques and what we were really interested in was terms relating to determinants, predictors, factors that investigated preventable admissions as well as the chronic conditions most likely to result in preventable illness episodes.

MB: And your work identified 3 major clusters of priority factors nicely summed up as person, program and place. Could you elaborate on these factors for our listeners?

HM: Sure, well what we found from our review was that there was indeed a socially determined framework to understand how people with chronic diseases were coming into hospitals for treatment when they could’ve been treated in the community and what this means is that hospitalisation was really the result of a broad range of factors, not limited to individual determinants such as gender and age but certainly depended on health management, where someone lived, their capacity to be supported within the home environment, the level of care coordination they may have been receiving from their GP, whether or not they had health action plans and insurance etcetera. So there were a huge number of factors that could explain the situation more so than someone’s inability to manage their acute conditions. We then looked at the factors that could be amended with deliberate action on behalf of government and health services, so that’s where the priority factors came in. So what we found was the 3 main clusters as you said, person priorities, program priorities and place priorities. For person priorities, they’re rather the individual components that are more related to symptom management of co-occurring conditions, so we found that people with one chronic condition usually had a couple of other conditions there as well that needed to be managed. So someone with diabetes was also overweight and may of also had asthma or something like that. Also important in that person priorities were the supportive relationships that people had around them, so their health status depended on how they sought help with other people. Making health decisions was really about how they involved other people in their life. With the program priorities we found that the self-management supports were critical there and that’s not just about being able to self-manage but the supports that are around you to enable you to do that. So that is whether the GP was able to develop a personalised action plan for you, so from Monday through to Sunday you had a daily program of the things that you needed to do to maintain your health and wellbeing, what medications you needed to take, all those sorts of daily management strategies. Within the program priorities there were also service coordination as a critical factor there and that means things like care planning, good transfer process between one health service and another or one GP and a health service or a specialist, multi-disciplinary care, so involving a lot of other people in that individual’s health management and interestingly within that service coordination determinant what was also crucial was the relationship with the GP and the number of visits to the GP that that person might of had in the last 12 months. So even though there wasn’t a great deal of research published on that in our systematic review of the literature there was certainly a burgeoning evidence to suggest that the relationship with the GP is really quite important, it’s probably under-researched, there’s some components in there around the quality of that relationship and the knowingness of the GP to be in touch with and predict I guess some of the health concerns for an individual patient. The third and final area was place priorities which were critical in itself in a bigger way and that really took things like the local neighbourhood, so where someone actually lived was very influential in their health status and we don’t normally think in those terms or certainly make those connections in a very intangible way. And what we found that there were some tangible reasons why living in a certain neighbourhood might impact health status and that was things like geographical remoteness, meaning that the access to transport to health services is less likely, it’s more likely that crisis care was going to happen so you know helicopters and other emergency services were likely to be mobilised because that person doesn’t generally or regularly go to preventative health clinics so that you had this situation where even though someone lived quite a way from ambulatory or community health services, they would really only access health when their health status got so bad that is was critical.

MB: When they’re in dire straits.

HM: Absolutely and a second component to that place priority factor was the social position of a person and that’s not just about whether or not they’re employed, but really what are the opportunities in that community for employment, what’s the uptake of health services due to insurance cover for instance. So lower socio-economic individuals and groups certainly have less access to health insurance, therefore less likelihood to access screening services or other entitlements that might come with private health cover. So there’s a lot of reasons there that we thought we need a broader approach to considering this issue and certainly government and policy makers need to think about a broader way. What that actually means is that overall hospitalisation for acute conditions and not crisis care can be prevented, we know it can be with an inclusive approach. It can be managed in the community with the GP and health services and what the results mean is we can improve a person’s health status, decrease their symptom severity, increase their access to self-management supports and reinforce their social networks and improve public access to community care, to actually use hospitals for what they’re intended and to make preventable hospitalisation actually preventable.

MB: Yes that would be a good outcome. Okay well thank you very much for talking with us today on this important topic.

HM: You’re welcome, thanks Michael.

This podcast was produced by the International Program of Psycho-Social Health Research (IPP-SHR), Griffith University for the Logan Research Showcase held on 6 September 2011. For further information contact Dr Pam McGrath at [email protected]