Specific long term condition combinations play major role in NHS ‘winter pressures’

Specific combinations of long term conditions play a major role in the additional pressures the NHS faces every winter, according to a new study led by the University of Southampton.

This is because they are associated with significantly higher risks of hospital admissions and death, the research, published in the journal BMJ Medicine , has found.

The risk of a hospital admission was 11 times higher among those with the quartet of cancer, kidney disease, cardiovascular disease, and type 2 diabetes than it was among those without any of these long term conditions, the findings show.

People with kidney disease, cardiovascular disease, dementia, and osteoarthritis were 24 times more likely to die as those who didn’t have these long term conditions.

“Our research identified combinations of long term conditions that are associated with substantially higher risks of winter hospitalisation and deaths. These findings will help inform more targeted planning for winter pressures, enabling resources to be allocated where they are needed the most,” comments lead author on the paper Dr Nazrul Islam , Associate Professor of Epidemiology and Medical Statistics at the University of Southampton.

Winter pressures are prompted by the worsening of health issues as a result of colder weather, seasonal viruses, increased isolation and loneliness, plus systems level difficulties caused by higher bed occupancy and staff absences, explain the researchers. These additional pressures usually cover the period from 1 December to March 31.

The number of people in England with two or more long term conditions is projected to include almost 70 percent of the population by 2035. While previously published research has established the increased health service demand related to multiple long term conditions during the winter, it’s not clear exactly which combinations might be the most critical.

To try and find this out, the researchers reviewed routinely collected and linked primary and secondary care health data for adults in England, during the winter pressures period of 2021-22, to identify the reasons for hospital admission. The data were accessed in NHS England’s Secure Data Environment service for England, via the BHF Data Science Centre’s CVD-COVID-UK/COVID-IMPACT Consortium.

Complete data were available for 48.3 million people, just over half of whom were women (51 percent). Their average age was 49, and 81 percent of them were white. The researchers selected 59 long term conditions which were categorised into 19 groups, based on feedback from clinicians, patients, and policy-makers.

During the study period, 4,710,675 hospital admissions and 176,895 deaths were recorded. Overall, nearly 20 million people (40.5 percent) had no long term conditions; 13.5 million had (28 percent) one; and nearly a third (15 million; 31 percent) had two or more.

Analysis of the data showed that particular combinations of long term conditions were associated with heightened risks of hospital admission and death. After adjusting for age, sex, ethnicity, and area based socioeconomic deprivation, people with cancer, kidney disease, cardiovascular disease, and type 2 diabetes were 11 times more likely to be admitted to hospital during the winter than those who didn’t have this combination.

Similarly, this risk was nearly 10 times higher for those with cancer, chronic kidney disease, cardiovascular disease, and osteoarthritis, and those with cancer, chronic kidney disease, and cardiovascular disease.

Among the 10 combinations that contributed to the highest rates of hospital admissions, cardiovascular disease featured in all but one, chronic kidney disease in eight, and cancer in six.

Analysis of the deaths linked to particular combinations of long term conditions showed that people with cardiovascular disease and dementia were nearly 15 times more likely to die than those with none of these conditions. Those with the combination of kidney disease, cardiovascular disease, dementia, and osteoarthritis were more than 24 times more likely to do so.

Cardiovascular disease featured in all 10 of the riskiest combinations, while chronic kidney disease featured in seven of them.

Cardiovascular disease plus dementia also featured in all of the top five riskiest combinations, and this duo was associated with a substantially higher rate of death than many three, four, and five long term condition combinations.

Dr Hajira Dambha-Miller , Associate Professor in Primary Care Research at the University of Southampton, says: “Our work extends the body of evidence on long-term conditions and potential social care needs, and advances our understanding of the risk and vulnerabilities of people living with multiple long term conditions.”

This is an observational study, precluding firm conclusions to be drawn about causal factors. The study adds critical insights during the COVID-19 pandemic when health and social care services were substantially disrupted. The researchers acknowledge various limitations to their findings, including the lack of information about the length or severity of illness or frailty.

The research paper ‘Combinations of multiple long-term conditions and risk of hospitalisation or death during winter 2021-22: population-based cohort study of 48 million people in England’ is published here: https://doi.org/10.1136/bmjmed-2024-001016