Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions

A systematic review of evidence on the association between hospitalisation for chronic disease related ambulatory care sensitive conditions and primary health care resourcing

Background

Primary health care is recognised as an integral part of a country’s health care system. Measuring hospitalisations, that could potentially be avoided with high quality and accessible primary care, is one indicator of how well primary care services are performing. This review was interested in the association between chronic disease related hospitalisations and primary health care resourcing.

Methods

Studies were included if peer reviewed, written in English, published between 2002 and 2012, modelled hospitalisation as a function of PHC resourcing and identified hospitalisations for type 2 diabetes as a study outcome measure. Access and use of PHC services were used as a proxy for PHC resourcing. Studies in populations with a predominant user pay system were excluded to eliminate patient financial barriers to PHC access and utilisation. Articles were systematically excluded based on the inclusion criteria, to arrive at the final set of studies for review.

Results

The search strategy identified 1778 potential articles using EconLit, Medline and Google Scholar databases. Ten articles met the inclusion criteria and were subject to review. PHC resources were quantified by workforce (either medical or nursing) numbers, number of primary care episodes, service availability (e.g. operating hours), primary care practice size (e.g. single or group practitioner practice—a larger practice has more care disciplines onsite), or financial incentive to improve quality of diabetes care. The association between medical workforce numbers and ACSC hospitalisations was mixed. Four of six studies found that less patients per doctor was significantly associated with a decrease in ambulatory care sensitive hospitalisations, one study found the opposite and one study did not find a significant association between the two. When results were categorised by PHC access (e.g. GPs/capita, range of services) and use (e.g. n out-patient visits), better access to quality PHC resulted in fewer ACSC hospitalisations. This finding remained when only studies that adjusted for health status were categorised. Financial incentives to improve the quality of diabetes care were associated with less ACSC hospitalisations, reported in one study.

Conclusion

Seven of 12 measures of the relationship between PHC resourcing and ACSC hospitalisations had a significant inverse association. As a collective body of evidence the studies provide inconclusive support that more PHC resourcing is associated with reduced hospitalisation for ACSC. Characteristics of improved or increased PHC access showed inverse significant associations with fewer ACSC hospitalisations after adjustment for health status. The varied measures of hospitalisation, PHC resourcing, and health status may contribute to inconsistent findings among studies and make it difficult to interpret findings.

Disparities in access to health care in three French regions

OBJECTIVES

This paper compares access to primary and specialty care in three metropolitan regions of France: Ile de France (IDF), Nord-Pas-de-Calais (NPC) and Provence-Alpes-Côte d'Azur (PACA); and identifies the factors that contribute to disparities in access to care within and among these regions.

METHODS

To assess access to primary care, we compare variation among residence-based, age-adjusted hospital discharge rates for ambulatory care sensitive conditions (ASC). To assess access on one dimension of specialty care, we compare residence-based, age-adjusted hospital discharge rates for revascularization - bypass surgery and angioplasty - among patients diagnosed with ischemic heart disease (IHD). In addition, for each region we rely on a multilevel generalized linear mixed effect model to identify a range of individual and area-level factors that affect the discharge rates for ASC and revascularization.

RESULTS

In comparison with other large metropolitan regions, in France, access to primary care is greater in Paris and its surrounding region (IDF) than in NPC but worse than in PACA. With regard to revascularization, after controlling for the burden of IHD, use of services is highest in PACA followed by IDF and NPC. In all three regions, disparities in access are much greater for revascularization than for ASC. Residents of low-income areas and those who are treated in public hospitals have poorer access to primary care and revascularizations. In addition, the odds of hospitalization for ASC and revascularization are higher for men. Finally, people who are treated in public hospitals, have poorer access to primary care and revascularization services than those who are admitted for ASC and revascularization services in private hospitals.

CONCLUSIONS

Within each region, we find significant income disparities among geographic areas in access to primary care as well as revascularization. Even within a national health insurance system that minimizes the financial barriers to health care and has one of the highest rates of spending on health care in Europe, the challenge of minimizing these disparities remains.

Impact of the Family Health Program on gastroenteritis in children in Bahia, Northeast Brazil: an analysis of primary care-sensitive conditions

In seeking to provide universal health care through its primary care-oriented Family Health Program, Brazil has attempted to reduce hospitalization rates for preventable illnesses such as childhood gastroenteritis. We measured rates of Primary Care-sensitive Hospitalizations and evaluated the impact of the Family Health Program on pediatric gastroenteritis trends in high-poverty Northeast Brazil. We analyzed aggregated municipal-level data in time-series between years 1999–2007 from the Brazilian health system payer database and performed qualitative, in-depth key informant interviews with public health experts in municipalities in Bahia. Data were sampled for Bahia’s Salvador microregion, a population of approximately 14 million. Gastroenteritis hospitalization rates among children aged less than 5 years were evaluated. Declining hospitalization rates were associated with increasing coverage by the PSF (P = 0.02). After multivariate adjustment for garbage collection, sanitation, and water supply, evidence of this association was no longer significant (P = 0.28). Qualitative analysis confirmed these findings with a framework of health determinants, proximal causes, and health system effects. The PSF, with other public health efforts, was associated with decreasing gastroenteritis hospitalizations in children. Incentives for providers and more patient-centered health delivery may contribute to strengthening the PSF’s role in improving primary health care outcomes in Brazil.

Small area analysis of ambulatory care sensitive conditions in Victoria, Australia

Ambulatory care sensitive conditions (ACSCs) are used as a measure of access to primary health care. The purpose of this study was to identify factors associated with variation in ACSC admissions at a small area level in Victoria, Australia. The study was ecologic, using Victorian Primary Care Partnerships (PCPs) as the unit of analysis. Data sources were the Victorian Admitted Episodes Dataset, census data from the Australian Bureau of Statistics, and the Victorian Population Health Survey. Age- and sex-adjusted total ACSC admission rates were calculated, and weighted least squares multiple linear regression was used to examine the associations of total ACSC admission rates by various predictor variables. Key variables were categorized into 1 of 4 framework components for analyzing access and use of health care services: predisposing, enabling, need, or structural. Enabling characteristics explained 61.70% of the variation in ACSC admission rates across PCPs. Socioeconomic characteristics (income, education) and percentage with poor self-rated health were important factors in explaining variations in ACSC admissions at a small area-level [R(2)=0.77]. Community-level variables differentially affect access to primary health care, with significant variation by socioeconomic status. This analytical approach will assist researchers to identify community-level predicators of access across populations at locations, including factors that may be affected by policy change.

Is secondary preventive care improving? Observational study of 10-year trends in emergency admissions for conditions amenable to ambulatory care

OBJECTIVE

To identify trends in emergency admissions for patients with clinical conditions classed as 'ambulatory care sensitive' (ACS) and assess if reductions might be due to improvements in preventive care.

DESIGN

Observational study of routinely collected hospital admission data from March 2001 to April 2011. Admission rates were calculated at the population level using national population estimates for area of residence.

PARTICIPANTS

All emergency admissions to National Health Service (NHS) hospitals in England from April 2001 to March 2011 for people residents in England.

MAIN OUTCOME MEASURES

Age-standardised emergency admissions rates for each of 27 specific ACS conditions (ICD-10 codes recorded as primary or secondary diagnoses).

RESULTS

Between April 2001 and March 2011 the number of admissions for ACS conditions increased by 40%. When ACS conditions were defined solely on primary diagnosis, the increase was less at 35% and similar to the increase in emergency admissions for non-ACS conditions. Age-standardised rates of emergency admission for ACS conditions had increased by 25%, and there were notable variations by age group and by individual condition. Overall, the greatest increases were for urinary tract infection, pyelonephritis, pneumonia, gastroenteritis and chronic obstructive pulmonary disease. There were significant reductions in emergency admission rates for angina, perforated ulcers and pelvic inflammatory diseases but the scale of these successes was relatively small.

CONCLUSIONS

Increases in rates of emergency admissions suggest that efforts to improve the preventive management of certain clinical conditions have failed to reduce the demand for emergency care. Tackling the demand for hospital care needs more radical approaches than those adopted hitherto if reductions in emergency admission rates for ACS conditions overall are to be seen as a positive outcome of for NHS.

Long-term impact of environmental public health disaster on health system performance: experiences from the Graniteville, South Carolina chlorine spill

OBJECTIVES

In the aftermath of an environmental public health disaster (EPHD) a healthcare system may be the least equipped entity to respond. Preventable visits for ambulatory care-sensitive conditions (ACSCs) may be used as a population-based indicator to monitor health system access postdisaster. The objective of this study was to examine whether ACSC rates among vulnerable subpopulations are sensitive to the impact of a disaster.

METHODS

We conducted a retrospective analysis on the 2005 chlorine spill in Graniteville, South Carolina using a Medicaid claims database. Poisson regression was used to calculate change in monthly ACSC visits at the disaster site in the postdisaster period compared with the predisaster period after adjusting for parallel changes in a control group.

RESULTS

The adjusted rate of a predisaster ACSC hospital visit for the direct group was 1.68 times the rate for the control group (95% confidence interval [CI] 1.47-1.93), whereas the adjusted ACSC hospital rate postdisaster for the direct group was 3.10 times the rate for the control group (95% CI 1.97-5.18). For ED ACSC visits, the adjusted rate among those directly affected predisaster were 1.82 times the rate for the control group (95% CI 1.61-2.08), whereas the adjusted ACSC rate postdisaster was 2.81 times the rate for the control group (95% CI 1.92-5.17).

CONCLUSIONS

Results revealed that an increased demand on the health system altered health services delivery for vulnerable populations directly affected by a disaster. Preventable visits for ACSCs may advance public health practice by identifying healthcare disparities during disaster recovery.

Patient characteristics associated with hospitalisations for ambulatory care sensitive conditions in Victoria, Australia

Background

Ambulatory Care Sensitive Conditions (ACSCs) are those for which hospitalisation is thought to be avoidable with the application of preventive care and early disease management, usually delivered in a primary care setting. ACSCs are used extensively as indicators of accessibility and effectiveness of primary health care. We examined the association between patient characteristics and hospitalisation for ACSCs in the adult and paediatric population in Victoria, Australia, 2003/04.

Methods

Hospital admissions data were merged with two area-level socioeconomic indexes: Index of Socio-Economic Disadvantage (IRSED) and Accessibility/Remoteness Index of Australia (ARIA). Univariate and multiple logistic regressions were performed for both adult (age 18+ years) and paediatric (age <18 years) groups, reporting odds ratios (OR) and 95% confidence intervals (CI) for a number of predictors of ACSCs admissions compared to non-ACSCs admissions.

Results

Predictors were much more strongly associated with ACSCs admissions compared to non-ACSCs admissions in the adult group than for the paediatric group with the exception of rurality. Significant adjusted ORs in the adult group were 1.06, 1.15, 1.13, 1.06 and 1.11 for sex, rurality, age, IRSED and ARIA variables, and 1.34, 1.04 and 1.09 in the paediatric group for rurality, IRSED and ARIA, respectively.

Conclusions

Disadvantaged paediatric and adult population experience more need of hospital care for ACSCs. Access barriers to primary care are plausible causes for the observed disparities. Understanding the characteristics of individuals experiencing access barriers to primary care will be useful for developing targeted interventions meeting the unique ambulatory needs of the population.

Assessing Preventable Hospitalisation InDicators (APHID): protocol for a data-linkage study using cohort study and administrative data

INTRODUCTION

Potentially preventable hospitalisation (PPH) has been adopted widely by international health systems as an indicator of the accessibility and overall effectiveness of primary care. The Assessing Preventable Hospitalisation InDicators (APHID) study will validate PPH as a measure of health system performance in Australia and Scotland. APHID will be the first large-scale study internationally to explore longitudinal relationships between primary care and PPH using detailed person-level information about health risk factors, health status and health service use.

METHODS AND ANALYSIS

APHID will create a new longitudinal data resource by linking together data from a large-scale cohort study (the 45 and Up Study) and prospective administrative data relating to use of general practitioner (GP) services, dispensing of pharmaceuticals, emergency department presentations, hospital admissions and deaths. We will use these linked person-level data to explore relationships between frequency, volume, nature and costs of primary care services, hospital admissions for PPH diagnoses, and health outcomes, and factors that confound and mediate these relationships. Using multilevel modelling techniques, we will quantify the contributions of person-level, geographic-level and service-level factors to variation in PPH rates, including socioeconomic status, country of birth, geographic remoteness, physical and mental health status, availability of GP and other services, and hospital characteristics.

ETHICS AND DISSEMINATION

Participants have consented to use of their questionnaire data and to data linkage. Ethical approval has been obtained for the study. Dissemination mechanisms include engagement of policy stakeholders through a reference group and policy forum, and production of summary reports for policy audiences in parallel with the scientific papers from the study.

Secondary surge capacity: a framework for understanding long-term access to primary care for medically vulnerable populations in disaster recovery

Disasters create a secondary surge in casualties because of the sudden increased need for long-term health care. Surging demands for medical care after a disaster place excess strain on an overtaxed health care system operating at maximum or reduced capacity. We have applied a health services use model to identify areas of vulnerability that perpetuate health disparities for at-risk populations seeking care after a disaster. We have proposed a framework to understand the role of the medical system in modifying the health impact of the secondary surge on vulnerable populations. Baseline assessment of existing needs and the anticipation of ballooning chronic health care needs following the acute response for at-risk populations are overlooked vulnerability gaps in national surge capacity plans.

Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage

BACKGROUND

The continued increase in hospital admissions is a significant and complex issue facing health services. There is little research exploring patient perspectives or examining individual admissions among patients with frequent admissions for chronic ambulatory care sensitive (ACS) conditions. This paper aims to describe characteristics of older, rural patients frequently admitted with ACS conditions and identify factors associated with their admissions from the patient perspective.

METHODS

Patients aged 65+ resident in North Coast NSW with three or more admissions for selected ACS chronic conditions within a 12 month period, were invited to participate in a postal survey and follow up telephone call. Survey and telephone data were linked to admission and health service program data. Descriptive statistics were generated for survey respondents; logistic regression models developed to compare characteristics of patients with 3 or with 4+ admissions; and comparisons made between survey respondents and non-respondents.

RESULTS

Survey respondents (n=102) had a mean age of 77.1 years (range 66-95 years), and a mean of 4.1 admissions within 12 months; 49% had at least three chronic conditions; the majority had low socioeconomic status; one in five (22%) reported some difficulty affording their medication; and 35% lived alone. The majority reported psychological distress with 31% having moderate or severe psychological distress. While all had a GP, only 38% reported having a written GP care plan. 22% of those who needed regular help with daily tasks did not have a close friend or relative who regularly cared for them. Factors independently associated with more frequent (n=4+) relative to less frequent (n=3) admissions included having congestive heart failure (p=0.003), higher social isolation scores (p=0.040) and higher Charlson Comorbidity Index scores (p=0.049). Most respondents (61%) felt there was nothing that could have avoided their most recent admission, although some potential avoidability of admission was described around medication and health behaviours. Respondents were younger and less sick than non-respondents.

CONCLUSIONS

This study provides a detailed description of older patients with multiple chronic conditions and a history of frequent admission in rural Australia. Our results suggest that programs targeting medication use, health behaviours and social isolation may help reduce multiple hospital admissions for chronic disease.

Changes in preventable hospitalization patterns among the adults: a small area analysis of US states

The study examines the variation and changes in preventable hospitalization (PH) rates across small areas over 1995-2005 in 5 US states for adults (aged 18-64 years). Using hospital discharge data from the Agency for Healthcare Research and Quality and contextual data from Health Resources and Services Administration, the study examines the role of managed care, primary care physician supply, and sociodemographic factors on adult PH rates. A stronger influence of minority and uninsured status, weaker contributions of managed care enrollment in the commercial as well as in the Medicaid markets, and weaker contributions of primary care density may have caused slower than expected reduction in adult PH rates.

Prediction of unmet primary care needs for the medically vulnerable post-disaster: an interrupted time-series analysis of health system responses

Disasters serve as shocks and precipitate unanticipated disturbances to the health care system. Public health surveillance is generally focused on monitoring latent health and environmental exposure effects, rather than health system performance in response to these local shocks. The following intervention study sought to determine the long-term effects of the 2005 chlorine spill in Graniteville, South Carolina on primary care access for vulnerable populations. We used an interrupted time-series approach to model monthly visits for Ambulatory Care Sensitive Conditions, an indicator of unmet primary care need, to quantify the impact of the disaster on unmet primary care need in Medicaid beneficiaries. The results showed Medicaid beneficiaries in the directly impacted service area experienced improved access to primary care in the 24 months post-disaster. We provide evidence that a health system serving the medically underserved can prove resilient and display improved adaptive capacity under adverse circumstances (i.e., technological disasters) to ensure access to primary care for vulnerable sub-groups. The results suggests a new application for ambulatory care sensitive conditions as a population-based metric to advance anecdotal evidence of secondary surge and evaluate pre- and post-health system surge capacity following a disaster.

Canadian rural-urban differences in end-of-life care setting transitions

Few studies have focused on the care setting transitions that occur in the last year of life. A three part mixed-methods study was conducted to gain an understanding of the number and implications or impact of care setting transitions in the last year of life for rural Canadians. Provincial health services utilization data, national online survey data, and local qualitative interview data were analyzed to gain general and specific information for consideration. Rural Albertans had significantly more healthcare setting transitions than urbanites in the last year of life (M=4.2 vs 3.3). Online family respondents reported 8 moves on average occurred for family members in the last year of life. These moves were most often identified (65%) on a likert-type scale as “very difficult,” with the free text information revealing these trips were often emotionally painful for themselves and physically painful for their ill family member. Eleven informants were then interviewed until data saturation, with constant-comparative data analysis conducted for a more in-depth understanding of rural transitions. Moving from place to place for needed care in the last year of life was identified as common and concerning for rural people and their families, with three data themes developing: (a) needed care in the last year of life is scattered across many places, (b) travelling is very difficult for terminally-ill persons and their caregivers, and (c) local rural services are minimal. These findings indicate planning is needed to avoid unnecessary end-of-life care setting transitions and to make needed moves for essential services in the last year of life less costly, stressful, and socially disruptive for rural people and their families.

Reduction of ambulatory care sensitive conditions in Brazil between 1998 and 2009

OBJECTIVE

To describe the trends in hospitalizations for ambulatory care sensitive conditions between 1998 and 2009 in Brazil.

METHODS

The ecological time series study used secondary data on hospitalizations for ACSC in the Sistema Único de Saúde (SUS, National Unified Health System). Data were obtained from the Hospital Information System. Hospital admission rates per 10,000 inhabitants were standardized by age range and gender, using the 2000 census male Brazilian population as standard. Trend analysis of the historic series was performed through generalized linear regression using the Prais-Winsten method.

RESULTS

Between 1998 and 2009, there was an average annual reduction in admissions for ambulatory care sensitive conditions of 3.7% in men (95%CI -2.3;-5.1) and women (95%CI -2.5; -5.6). The trend varied in each state, although no increase in admissions was observed in any state. In both men and women, the highest reductions were observed in hospitalizations for gastrointestinal ulcers (-11.7% a year and -12.1%, respectively), avoidable conditions (-8.8% and -8.9%) and lower respiratory diseases (-8.0% and -8.1%). Hospitalization increased only for angina (men), kidney infections and urinary tract infections (men and women) and conditions related to prenatal care and delivery (women). The three groups of illness which led to the most admissions were infectious gastroenteritis and its complications, cardiac insufficiency and asthma.

CONCLUSIONS

Between 1998 and 2009, there was a substantial reduction in admissions for ambulatory care sensitive conditions in Brazil, although some illnesses presented stability or even an increase, which calls for attention from the health sector.

Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012

As of 2005, the literature on the benefits of primary care oriented health systems was consistent in showing greater effectiveness, greater efficiency, and greater equity. In the ensuing five years, nothing changed that conclusion, but there is now greater understanding of the mechanisms by which the benefits of primary care are achieved. We now know that, within certain bounds, neither the wealth of a country nor the total number of health personnel are related to health levels. What counts is the existence of key features of health policy (Primary Health Care): universal financial coverage under government control or regulation, attempts to distribute resources equitably, comprehensiveness of services, and low or no copayments for primary care services. All of these, in combination, produce better primary care: greater first contact access and use, more person-focused care over time, greater range of services available and provided when needed, and coordination of care. The evidence is no longer confined mainly to industrialized countries, as new studies show it to be the case in middle and lower income countries. The endorsements of the World Health Organization (in the form of the reports of the Commission on Social Determinants of Health and the World Health Report of 2008, as well a number of other international commissions, reflect the widespread acceptance of the importance of primary health care. Primary health care can now be measured and assessed; all innovations and enhancements in it must serve its essential features in order to be useful.

Frequent emergency attenders: is there a better way?

BACKGROUND

Understanding the reasons for frequent re-attendances will assist in developing solutions to hospital overcrowding. This study aimed to identify the factors associated with frequent re-attendances in a regional hospital thereby highlighting possible solutions to the problem.

METHODS

A retrospective analysis was performed on emergency department data from 2008. Frequent re-attenders were defined as those with four or more presentations in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on re-presentations using multivariate analysis. RESULTS; A total of 8% of the total patients presenting to emergency re-attended four or more times in the year. Frequent re-attenders were older, presented with an unplanned returned visit and had a diagnosis of neurosis, chronic obstructive pulmonary disease (COPD), convulsions, dyspnoea or repeat prescriptions, follow-up examinations or dressings and sutures and less likely to present in summer. Frequent re-attendances were unrelated to sex, time of presentation or country of birth.

CONCLUSIONS

Diversion of patients with minor conditions to alternative services; referral of COPD patients to follow-up respiratory services and patients with neurosis to community mental health services would reduce emergency utilisation. Improving access to and resourcing of alternative non-hospital services should be investigated to reduce emergency overcrowding.

Medicare managed care plan performance: a comparison across hospitalization types

OBJECTIVE

The study evaluates the performance of Medicare managed care (Medicare Advantage [MA]) Plans in comparison to Medicare fee-for-service (FFS) Plans in three states with historically high Medicare managed care penetration (New York, California, Florida), in terms of lowering the risks of preventable or ambulatory care sensitive conditions (ACSC) hospital admissions and providing increased referrals for admissions for specialty procedures.

STUDY DESIGN/METHODS

Using 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP-SID) of the Agency for Healthcare Research and Quality, ACSC admissions are compared with 'marker' admissions and 'referral-sensitive' admissions, using a multinomial logistic regression approach. The year 2004 represents a strategic time to test the impact of MA on preventable hospitalizations, because the HMOs dominated the market composition in that time period.

FINDINGS

MA enrollees in California experienced 22% lower relative risk (RRR= 0.78, p<0.01), those in Florida experienced 16% lower relative risk (RRR= 0.84, p<0.01), while those in New York experienced 9% lower relative risk (RRR=0.91, p<0.01) of preventable (versus marker) admissions compared to their FFS counterparts. MA enrollees in New York experienced 37% higher relative risk (RRR=1.37, p<0.01) and those in Florida had 41% higher relative risk (RRR=1.41, p<0.01)-while MA enrollees in California had 13% lower relative risk (RRR=0.87, p<0.01)-of referral-sensitive (versus marker) admissions compared to their FFS counterparts.

CONCLUSION

While MA plans were associated with reductions in preventable hospitalizations in all three states, the effects on referral-sensitive admissions varied, with California experiencing lower relative risk of referral-sensitive admissions for MA plan enrollees. The lower relative risk of preventable admissions for MA plan enrollees in New York and Florida became more pronounced after accounting for selection bias.

Expanding the uses of AHRQ's prevention quality indicators: validity from the clinician perspective

BACKGROUND

The Agency for Healthcare Research and Quality's prevention quality indicators (PQIs) are used as a metric of area-level access to quality care. Recently, interest has expanded to using the measures at the level of payer or large physician groups, including public reporting or pay-for-performance programs. However, the validity of these expanded applications is unknown.

RESEARCH DESIGN

We conducted a novel panel process to establish face validity of the 12 PQIs at 3 denominator levels: geographic area, payer, and large physician groups; and 3 uses: quality improvement, comparative reporting, and pay for performance. Sixty-four clinician panelists were split into Delphi and Nominal Groups. We aimed to capitalize on the reliability of the Delphi method and information sharing in the Nominal group method by applying these techniques simultaneously. We examined panelists' perceived usefulness of the indicators for specific uses using median scores and agreement within and between groups.

RESULTS

Panelists showed stronger support of the usefulness of chronic disease indicators at the payer and large physician group levels than for acute disease indicators. Panelists fully supported the usefulness of 2 indicators for comparative reporting (asthma, congestive heart failure) and no indicators for pay-for-performance applications. Panelists expressed serious concerns about the usefulness of all new applications of 3 indicators (angina, perforated appendix, dehydration). Panelists rated age, current comorbidities, earlier hospitalization, and socioeconomic status as the most important risk-adjustment factors.

CONCLUSIONS

Clinicians supported some expanded uses of the PQIs, but generally expressed reservations. Attention to denominator definitions and risk adjustment are essential for expanded use.

Age-Based Differences in Care Setting Transitions over the Last Year of Life

Context. Little is known about the number and types of moves made in the last year of life to obtain healthcare and end-of-life support, with older adults more vulnerable to care setting transition issues. Research Objective. Compare care setting transitions across older (65+ years) and younger individuals. Design. Secondary analyses of provincial hospital and ambulatory database data. Every individual who lived in the province for one year prior to death from April 1, 2005 through March 31, 2007 was retained (N = 19, 397). Results. Transitions averaged 3.5, with 3.9 and 3.4 for younger and older persons, respectively. Older persons also had fewer ER and ambulatory visits, fewer procedures performed in the last year of life, but longer inpatient stays (42.7 days versus 36.2 for younger persons). Conclusion. Younger and older persons differ somewhat in the number and type of end-of-life care setting transitions, a matter for continuing research and healthcare policy.

Trends in hospitalizations for primary care sensitive conditions following the implementation of Family Health Teams in Belo Horizonte, Brazil

OBJECTIVES

How to provide effective and efficient care to the burgeoning and aging populations of the major cities of low- and middle-income countries constitutes one of the principle public health issues of our times. We evaluated the Family Health Strategy, the Brazilian national health system's public approach to primary health care, in the major city of Belo Horizonte, describing trends and factors associated with hospitalizations for primary care sensitive conditions following the implementation of 506 family health teams, most of which were established in 2002.

METHODS

We conducted an ecological study covering 2003 to 2006, using mixed models to investigate time trends in public system hospitalizations as well as their association with social vulnerability and primary care team characteristics.

RESULTS

Sensitive conditions accounted for 115,340 (26.4%) hospitalizations. Over the 4-year period, hospitalizations for sensitive conditions declined by 17.9%, vs only 8.3% for non-sensitive ones (P<0.001). Hospitalization for sensitive conditions declined 22% for women in areas of high social vulnerability vs 9% for women in areas of low vulnerability (P<0.001); for men, 17% vs 10% (P=0.11).

CONCLUSIONS

Though the ecologic nature of our study limits the confidence with which conclusions can be affirmed, the Family Health Strategy appears to have contributed to a major reduction in hospitalizations due to primary care sensitive conditions in this large Brazilian metropolis, while at the same time promoting greater health equity.

The influence of primary care and hospital supply on ambulatory care-sensitive hospitalizations among adults in Brazil, 1999-2007

OBJECTIVES

We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care-sensitive (ACS) hospitalizations among adults in Brazil.

METHODS

We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables.

RESULTS

The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds.

CONCLUSIONS

These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

Principais causas de internação por condições sensíveis à atenção primária no Brasil: uma análise por faixa etária e região

OBJETIVOS: analisar as tendências das principais causas de internações hospitalares entre aquelas sensíveis à atenção primária (ICSAP) no Brasil, por faixa etária e região, no período de 1999 a 2006. MÉTODOS: trata-se de um estudo ecológico misto das tendências das três principais causas de ICSAP em menores de vinte anos. Os dados secundários foram provenientes do Sistema de Informação Hospitalar (SIH-SUS) e do censo demográfico do ano de 2001 e projeções populacionais do Instituto Brasileiro de Geografia e Estatística (IBGE). RESULTADOS: as três principais causas de ICSAP, em menores de 20 anos, foram as gastroenterites, asma e as pneumonias bacterianas. Houve redução das taxas de internação por gastroenterites (-12,0%) e asma (-31,8%) e, incremento de 142,5% nas taxas de internações por pneumonias bacterianas, tendências que ocorreram de forma distinta por faixa etária e região. CONCLUSÕES: a descrição das tendências temporais revelou mudanças positivas na evolução das taxas de internações por asma e gastroenterites infecciosas e negativas nas internações por pneumonia. Uma vez que estes problemas de saúde constituem objeto de intervenção prioritária na atenção primária, tais achados evidenciam a necessidade de se aprofundar a análise e reflexão sobre os determinantes do perfil das internações hospitalares no país.

Patient related factors in frequent readmissions: the influence of condition, access to services and patient choice

Background

People use emergency department services for a wide variety of health complaints, many of which could be handled outside hospitals. Many frequent readmissions are due to problems with chronic disease and are preventable. We postulated that patient related factors such as the type of condition, demographic factors, access to alternative services outside hospitals and patient preference for hospital or non-hospital services would influence readmissions for chronic disease. This study aimed to explore the link between frequent readmissions in chronic disease and these patient related factors.

Methods

A retrospective analysis was performed on emergency department data collected from a regional hospital in NSW Australia in 2008. Frequently readmitted patients were defined as those with three or more admissions in a year. Clinical, service usage and demographic patient characteristics were examined for their influence on readmissions using multivariate analysis.

Results

The emergency department received about 20,000 presentations a year involving some 16,000 patients. Most patients (80%) presented only once. In 2008 one hundred and forty four patients were readmitted three or more times in a year. About 20% of all presentations resulted in an admission. Frequently readmitted patients were more likely to be older, have an urgent Triage classification, present with an unplanned returned visit and have a diagnosis of neurosis, chronic obstructive pulmonary disease, dyspnoea or chronic heart failure. The chronic ambulatory care sensitive conditions were strongly associated with frequent readmissions. Frequent readmissions were unrelated to gender, time, day or season of presentation or country of birth.

Conclusions

Multivariate analysis of routinely collected hospital data identified that the factors associated with frequent readmission include the type of condition, urgency, unplanned return visit and age. Interventions to improve patient uptake of chronic disease management services and improving the availability of alternative non-hospital services should reduce the readmission rate in chronic disease patients.

[Ambulatory care sensitive hospitalizations: elaboration of Brazilian list as a tool for measuring health system performance (Project ICSAP--Brazil)]

Ambulatory care sensitive hospitalizations are a set of conditions for which access to effective primary care can reduce the likelihood of hospitalization. These hospitalizations have been used as an indicator of primary care performance in several countries and in three Brazilian states, but there is little consensus on which conditions should be included in this indicator. This paper presents a description of the steps undertaken to construct and validate a list for Brazil. The final list includes 20 groups of diagnostic conditions that represented 28.3% of a total of 2.8 million hospitalizations in the National Unified Health System in 2006. Gastroenteritis and complications, congestive heart failure, and asthma represented 44.1% of all ambulatory care sensitive hospitalizations. From 2000 to 2006, ambulatory care sensitive hospitalizations decreased by 15.8%, and this reduction was more significant than that observed in all other hospitalizations. The article concludes with potential applications and limitations of the proposed Brazilian list.

Hospitalizações por condições sensíveis à atenção primária nos municípios em gestão plena do sistema no Estado do Rio Grande do Sul, Brasil

Avaliou-se a qualidade dos cuidados oferecidos nos municípios em gestão plena no Rio Grande do Sul, Brasil, por meio da taxa de internações hospitalares por condições sensíveis à atenção primária, no período de 1995 a 2005. Foram consideradas as internações hospitalares por: diabetes mellitus, insuficiência cardíaca, hipertensão arterial, doença pulmonar obstrutiva crônica e doenças imunopreveníveis em indivíduos na faixa etária de 20 a 59 anos. Verificou-se diminuição das taxas em quase todos os municípios do estado. A regressão de Poisson não mostrou tendências de diminuição das taxas após a adesão à gestão plena. Nos municípios menores, as taxas foram mais elevadas. As internações por condições sensíveis à atenção ambulatorial mostraram-se indicadores de fácil operação e de baixo custo que podem produzir conhecimentos sobre os sistemas de saúde, possibilitando a melhoria de sua qualidade.

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

BACKGROUND

A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.

METHODS

From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.

RESULTS

Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.

CONCLUSIONS

The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

Internações sensíveis na atenção primária como indicador de avaliação da Estratégia Saúde da Família

OBJETIVO: Identificar variáveis associadas a internações sensíveis ao cuidado primário. MÉTODOS: Inquérito de morbidade hospitalar realizado com amostra aleatória de 660 pacientes internados em enfermarias de clínica médica e cirúrgica de hospitais conveniados com o Sistema Único de Saúde, em Montes Claros, MG, de 2007 a 2008. Foram realizadas entrevistas com os pacientes e seus familiares utilizando formulário próprio e pesquisa aos prontuários. A definição das condições consideradas sensíveis ao cuidado primário baseou-se na lista do Ministério da Saúde. A associação entre variáveis socioeconômicas e de saúde com as internações sensíveis foi analisada utilizando-se análises bivariadas e de regressão logística múltipla. RESULTADOS: O percentual de internações sensíveis ao cuidado primário no grupo estudado foi de 38,8% (n=256). As variáveis que se mantiveram estatisticamente associadas com as condições sensíveis ao cuidado primário foram: internação prévia (OR=1,62; IC 95%: 1,51;2,28), visitas regulares a unidades de saúde (OR=2,20; IC 95%: 1,44;3,36), baixa escolaridade (OR=1,50; IC 95%: 1,02;2,20), controle de saúde não realizado por equipe de saúde da família (OR=2,48; IC 95%: 1,64;3,74), internação solicitada por médicos que não atuam na equipe de saúde da família (OR=2,25; IC 95%: 1,03;4,94) e idade igual ou superior a 60 anos (OR=2,12; IC 95%: 1,45;3,09). CONCLUSÕES: As variáveis associadas às internações sensíveis são sobretudo próprias do paciente, como idade, escolaridade e internações prévias, mas o controle regular da saúde fora da Estratégia de Saúde da Família duplica a probabilidade de internação.

Using hospitalization for ambulatory care sensitive conditions to measure access to primary health care: an application of spatial structural equation modeling

Background

In data commonly used for health services research, a number of relevant variables are unobservable. These include population lifestyle and socio-economic status, physician practice behaviors, population tendency to use health care resources, and disease prevalence. These variables may be considered latent constructs of many observed variables. Using health care data from South Carolina, we show an application of spatial structural equation modeling to identify how these latent constructs are associated with access to primary health care, as measured by hospitalizations for ambulatory care sensitive conditions. We applied the confirmatory factor analysis approach, using the Bayesian paradigm, to identify the spatial distribution of these latent factors. We then applied cluster detection tools to identify counties that have a higher probability of hospitalization for each of the twelve adult ambulatory care sensitive conditions, using a multivariate approach that incorporated the correlation structure among the ambulatory care sensitive conditions into the model.

Results

For the South Carolina population ages 18 and over, we found that counties with high rates of emergency department visits also had less access to primary health care. We also observed that in those counties there are no community health centers.

Conclusion

Locating such clusters will be useful to health services researchers and health policy makers; doing so enables targeted policy interventions to efficiently improve access to primary care.

Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states

Background

Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions.

Methods

We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios.

Results

Among working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHC-only counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78–0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81–0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84–0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations.

Conclusion

Our results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the county's rate of hospitalization for ACS diagnoses, particularly among older people.

Health information exchange and healthcare utilization

Health information exchange (HIE) makes previously inaccessible data available to clinicians, resulting in more complete information. This study tested the hypotheses that HIE information access reduced emergency room visits and inpatient hospitalizations for ambulatory care sensitive conditions among medically indigent adults. HIE access was quantified by how frequently system users' accessed patients' data. Encounter counts were modeled using zero inflated binomial regression. HIE was not accessed for 43% of individuals. Patient factors associated with accessed data included: prior utilization, chronic conditions, and age. Higher levels of information access were significantly associated with increased counts of all encounter types. Results indicate system users were more likely to access HIE for patients for whom the information might be considered most beneficial. Ultimately, these results imply that HIE information access did not transform care in the ways many would expect. Expectations in utilization reductions, however logical, may have to be reevaluated or postponed.

Funding of tribal health programs linked to lower rates of hospitalization for conditions sensitive to ambulatory care

OBJECTIVE

To determine first whether higher funding of Tribally Operated Health Programs (TOHP) is associated with reduced hospitalizations for ambulatory care sensitive conditions (HASC) of the American Indian/Alaska Natives (AIAN) who use them after adjusting for characteristics of TOHP service areas; and then whether improved ambulatory care with higher levels of funding mediates the association.

RESEARCH DESIGN

Records in the Indian Health Service (IHS) for California of an annual average 42,153 AIAN users of TOHP from 1998 to 2002 were linked with state hospital discharge records. We analyzed 3181 HASC for AIAN users of 20 TOHP in multilevel Poisson regression models to determine the association of HASC rates adjusted for individual age and gender with the Federal Disparity Index for IHS funding of TOHP.

RESULTS

Higher IHS funding of TOHP was associated with lower HASC rates for the AIAN who use them. For TOHP with less than 60% of health care costs funded, the HASC rate dropped 12% for every increase of 10% in funding. Even adjusting for characteristics of the service areas, the effect was only slightly reduced to a value of 9% to 11%. None of the available indicators of ambulatory care tested were found to mediate the effects.

CONCLUSIONS

Our findings are consistent with a policy of IHS funding of all TOHP at a level of at least 60% of the health care costs of the AIAN who use the programs, instead of the current policy of 40%. Additional research is needed to understand what ambulatory care characteristics are improved by the funding.

Developing 'robust performance benchmarks' for the next Australian Health Care Agreement: the need for a new framework

If the outcomes of the recent COAG meeting are implemented, Australia will have a new set of benchmarks for its health system within a few months. This is a non-trivial task. Choice of benchmarks will, explicitly or implicitly, reflect a framework about how the health system works, what is important or to be valued and how the benchmarks are to be used. In this article we argue that the health system is dynamic and so benchmarks need to measure flows and interfaces rather than simply cross-sectional or static performance. We also argue that benchmarks need to be developed taking into account three perspectives: patient, clinician and funder. Each of these perspectives is critical and good performance from one perspective or on one dimension doesn't imply good performance on either (or both) of the others.

The three perspectives (we term the dimensions patient assessed value, performance on clinical interventions and efficiency) can each be decomposed into a number of elements. For example, patient assessed value is influenced by timeliness, cost to the patient, the extent to which their expectations are met, the way they are treated and the extent to which there is continuity of care.

We also argue that the way information is presented is important: cross sectional, dated measures provide much less information and are much less useful than approaches based on statistical process control. The latter also focuses attention on improvement and trends, encouraging action rather than simply blame of poorer performers.

Preventable hospitalizations among children in California counties after child health insurance expansion initiatives

BACKGROUND

California has expanded health insurance to children in low- and middle-income families. Currently, Children's Health Initiatives (CHIs) have been developed in 26 counties to supplement Medi-Cal and Healthy Families (SCHIP). Yet, as coverage expands, we know little about the impact of these programs on child health outcomes.

RESEARCH DESIGN

Child hospitalizations for ambulatory care sensitive conditions (ACSC) is a widely adopted measure of health outcomes. We compare rates of total ACSC hospitalizations among children ages 0-18 years in 9 operational CHI counties prior to CHI implementation to rates after the CHIs became operational. As a comparison group, we stratify the analyses by family income level and compare children in lower-income to higher-income families.

RESULTS

Between 2000 and 2005, there were 281,000 total preventable hospital pediatric admissions. After adjusting for the effects of time and county, the rate of ACSC hospitalizations was 19% lower postimplementation of CHIs versus preimplementation for children of lower-income families (rate ratio of 0.81, P = 0.0001), but not for children of higher-income families (rate ratio of 0.99, P = 0.93).We estimate that 6324 ACSC hospitalizations may have already been prevented in existing CHI counties after implementation, saving about $6.7 million over the 6 years, assuming $7000 per child hospitalization.

CONCLUSIONS

With health insurance coverage available for all children, and families financially able to connect with an ongoing source of primary care, some of the potential benefits of reduced ACSC hospitalizations may help to offset premium costs associated with assuring that all children have coverage.

Geographic variations in avoidable hospitalizations in the elderly, in a health system with universal coverage

Background

The study of Hospitalizations for ambulatory care sensitive conditions (ACSH) has been proposed as an indirect measure of access to and receipt of care by older persons at the entryway to the Spanish public health system. The aim of this work is to identify the rates of ACSH in persons 65 years or older living in different small-areas of the Community of Madrid (CM) and to detect possible differences in ACSH.

Methods

Cross-sectional, ecologic study, which covered all 34 health districts of the CM. The study population consisted of all individuals aged 65 years or older residing in the CM between 2001 and 2003, inclusive. Using hospital discharge data, avoidable ACSH were selected from the list of conditions validated for Spain. Age- and sex-adjusted ACSH rates were calculated for the population of each health district and the statistics describing the data variability. Point graphs and maps were designed to represent the ACSH rates in the different health districts.

Results

Of all the hospitalizations, 16.5% (64,409) were ACSH. Globally, the rate was higher among men: 33.15 per 1,000 populations vs. 22.10 in women and these differences were statistically significant (p < 0.05) in each district. For men the range was 70.82 and the coefficient of variation (CV) was 0.47, while for women the range was 43.69 and the CV was 0.48. In 93.1% of cases, the ACSH were caused by hypertensive cardiovascular disease, heart failure or pneumonia. A centripetal pattern can be observed, with lower rates in the districts in the center of the CM. This geographic distribution is maintained after grouping by sex.

Conclusion

A significant variation is demonstrated in "preventable" hospitalizations between the different districts. In all the districts the men present rates significantly higher than women. Important variations in the access are observed the Primary Attention in spite of existing a universal sanitary cover.

A six-year descriptive analysis of hospitalisations for ambulatory care sensitive conditions among people born in refugee-source countries

Background

Hospitalisation for ambulatory care sensitive conditions (ACSHs) has become a recognised tool to measure access to primary care. Timely and effective outpatient care is highly relevant to refugee populations given the past exposure to torture and trauma, and poor access to adequate health care in their countries of origin and during flight. Little is known about ACSHs among resettled refugee populations. With the aim of examining the hypothesis that people from refugee backgrounds have higher ACSHs than people born in the country of hospitalisation, this study analysed a six-year state-wide hospital discharge dataset to estimate ACSH rates for residents born in refugee-source countries and compared them with the Australia-born population.

Methods

Hospital discharge data between 1 July 1998 and 30 June 2004 from the Victorian Admitted Episodes Dataset were used to assess ACSH rates among residents born in eight refugee-source countries, and compare them with the Australia-born average. Rate ratios and 95% confidence levels were used to illustrate these comparisons. Four categories of ambulatory care sensitive conditions were measured: total, acute, chronic and vaccine-preventable. Country of birth was used as a proxy indicator of refugee status.

Results

When compared with the Australia-born population, hospitalisations for total and acute ambulatory care sensitive conditions were lower among refugee-born persons over the six-year period. Chronic and vaccine-preventable ACSHs were largely similar between the two population groups.

Conclusion

Contrary to our hypothesis, preventable hospitalisation rates among people born in refugee-source countries were no higher than Australia-born population averages. More research is needed to elucidate whether low rates of preventable hospitalisation indicate better health status, appropriate health habits, timely and effective care-seeking behaviour and outpatient care, or overall low levels of health care-seeking due to other more pressing needs during the initial period of resettlement. It is important to unpack dimensions of health status and health care access in refugee populations through ad-hoc surveys as the refugee population is not a homogenous group despite sharing a common experience of forced displacement and violence-related trauma.