Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians

Does environmental regulation matter for healthcare utilisation in China? An interrupted time series study

In recent years, China has implemented a series of environmental regulation policies to improve air quality, but the health effects of these policy changes need to be accurately clarified and quantified. The objective of this study was to empirically examine the effects of levying construction dust pollution fees on healthcare utilisation in a southern city of China. The study used a unique administrative insurance claim dataset from the city's Urban Employee Basic Medical Insurance scheme between 2013 and 2015. The sample included 69,961 enrolees. An interrupted time series design was employed to investigate whether and how the healthcare utilisation of enrolees changed after the policy change. The results showed that this environmental regulation policy did not affect the inpatient utilisation of enrolees but did negatively impact outpatient utilisation. In addition, outpatient utilisation of chronic disease coverage decreased for patients with chronic diseases, including diabetes and hypertension. This study provides evidence that enhancing environmental regulations helps reduce medical costs, which can benefit China and other developing countries to improve environmental quality and promote public health.

Racial Disparities in Hospitalization Due to Ambulatory Care Sensitive Conditions Among U.S. Children with Autism

PURPOSE

This study was to investigate the factors associated with preventable hospitalization due to ambulatory care sensitive conditions (ACSCs) in children with autism.

METHODS

Using secondary data from the U.S. Nationwide Inpatient Sample (NIS), multivariable regression analyses were conducted to determine the potential effect of race and income level on the likelihood of inpatient stays for ACSCs among autistic children. Pediatric ACSCs included three acute conditions (dehydration, gastroenteritis, and urinary infection) and three chronic conditions (asthma, constipation, and diabetes short-term complications).

RESULTS

In this analysis, there were 21,733 hospitalizations among children with autism; about 10% were hospitalized due to pediatric ACSCs. Overall, the odds of ACSCs hospitalization were greater among Hispanic and Black autistic children versus White autistic children. Both Hispanic and Black autistic children from the lowest income level had the highest odds to be hospitalized for chronic ACSCs.

CONCLUSION

Inequities of access to health care among racial/ethnic minorities were most notable for autistic children with chronic ACSC conditions.

What can hospital emergency admissions prior to cancer diagnosis tell us about socio-economic inequalities in cancer diagnosis? Evidence from population-based data in England

BACKGROUND

More deprived cancer patients are at higher risk of Emergency Presentation (EP) with most studies pointing to lower symptom awareness and increased comorbidities to explain those patterns. With the example of colon cancer, we examine patterns of hospital emergency admissions (HEAs) history in the most and least deprived patients as a potential precursor of EP.

METHODS

We analysed the rates of hospital admissions and their admission codes (retrieved from Hospital Episode Statistics) in the two years preceding cancer diagnosis by sex, deprivation and route to diagnosis (EP, non-EP). To select the conditions (grouped admission codes) that best predict emergency admission, we adapted the purposeful variable selection to mixed-effects logistic regression.

RESULTS

Colon cancer patients diagnosed through EP had the highest number of HEAs than all the other routes to diagnosis, especially in the last 7 months before diagnosis. Most deprived patients had an overall higher rate and higher probability of HEA but fewer conditions associated with it.

CONCLUSIONS

Our findings point to higher use of emergency services for non-specific symptoms and conditions in the most deprived patients, preceding colon cancer diagnosis. Health system barriers may be a shared factor of socio-economic inequalities in EP and HEAs.

Medicaid Expansion and Preventable Emergency Department Use by Race/Ethnicity

INTRODUCTION

This study aimed to examine changes in emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) among uninsured or Medicaid-covered Black, Hispanic, and White adults aged 26-64 in the first 5 years of the Affordable Care Act Medicaid expansion.

METHODS

Using 2010-2018 inpatient and ED discharge data from nine expansion and five nonexpansion states, an event study difference-in-differences regression model was used to estimate changes in number of annual ACSC ED visits per 100 adults ("ACSC ED rate") associated with the 2014 Medicaid expansion, overall and by race/ethnicity. A secondary outcome was the proportion of ACSC ED visits out of all ED visits ("ACSC ED share"). Analyses were conducted in 2022-2023.

RESULTS

Medicaid expansion was associated with no change in ACSC ED rates among all, Black, Hispanic, or White adults. When excluding California, where most counties expanded Medicaid before 2014, expansion was associated with a decrease in ACSC ED rate among all, Black, Hispanic, and White adults. Expansion was also associated with a decrease in ACSC ED share among all, Black, and White adults. White adults experienced the largest reductions in ACSC ED rate and share.

CONCLUSIONS

Medicaid expansion was associated with reductions in ACSC ED rates in some expansion states and reductions in ACSC ED share in all expansion states combined, with some heterogeneity by race/ethnicity. Expansion should be coupled with policy efforts to better link newly insured Black and Hispanic patients to non-ED outpatient care, alongside targeted outreach and expanded primary care capacity, which may reduce disparities in ACSC ED visits.

The Academic Payvider Model: Care and Coverage

The US health care system has significant room for growth to achieve the Quintuple Aim. Reforming the relationship between payers and providers is pivotal to enhancing value-based care (VBC). The Payvider model, a joint approach to care and coverage rooted in vertical integration, is a potential solution. The authors aimed to investigate academic medical institutions adopting this model, termed Academic Payviders. All Association of American Medical Colleges (AAMC)-member allopathic medical schools were evaluated to identify programs meeting the inclusion criteria of offering both medical care and insurance coverage to patients via partnership with a payer or ownership of, or by, a payer. Twenty-five Academic Payvider systems were identified from 171 total AAMC-member programs. Most programs were founded after 2009 (n = 20), utilized a provider-dominant structural model (n = 17), and offered health plans to patients via Medicare Advantage (n = 23). Passage of the Affordable Care Act, recent trends in health care consolidation, and increased political and financial prioritization of social determinants of health (SDOH) may help to explain the rise of this care and coverage model. The Academic Payvider movement could advance academic medicine toward greater acceptance of VBC via innovations in medical education, resource stewardship in residency, and the establishment of innovative leadership positions at the administrative level.

Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system.

METHODS

We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016.

RESULTS

The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses.

CONCLUSIONS

The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway

BACKGROUND

Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients' contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions.

METHODS

Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009-2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and-demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals.

RESULTS

A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2-3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant.

CONCLUSION

As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers.

Evaluation of different models of general practitioners working in or alongside emergency departments: a mixed-methods realist evaluation

Background

Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models.

Objectives

To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models.

Design

Mixed-methods realist evaluation.

Methods

Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development.

Results

General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models.

Limitations

The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored.

Conclusion

Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services.

Future work

The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy.

Study registration

This study is registered as PROSPERO CRD42017069741.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

The Influence of the COVID-19 Pandemic on Hospitalizations for Ambulatory Care-Sensitive Conditions in Split-Dalmatia County, Croatia

Background and Objectives: We aimed to explore whether the COVID-19 pandemic influenced hospitalizations for ambulatory care-sensitive conditions (ACSCs) in Split-Dalmatia County, Croatia. Materials and Methods: We performed a cross-sectional comparative study using two different time periods, the pre-pandemic (from March 2019 to February 2020) and the pandemic period (from March 2020 to February 2021), to explore the possible influences that the COVID-19 pandemic had on hospitalizations for ACSCs. The ACSCs were classified into the categories of vaccine-preventable, chronic, and acute disease. The indicators were statistically analyzed. Results: During the pandemic, a decrease in the total number of hospitalizations and ACSC hospitalizations was recorded. The relative risk for having any ACSC hospitalization in the pandemic period compared to the pre-pandemic period was 0.67 (95% CI, 0.64-0.71; p = 0). The risk reduction was seen in all three categories of vaccine-preventable ACSCs, chronic disease, and acute disease. Large reductions were found in the relative risk of hospitalization for COPD and asthma. Considering the mode of discharge, there was a statistically significantly higher risk of ACSCs with fatal outcomes during the pandemic than in the pre-pandemic period (relative risk 1.31; 95% CI, 1.01-1.7; p = 0.0197). Conclusions: The results of this study show that the COVID-19 pandemic influenced the total number of hospitalizations as well as hospitalizations relating to ACSCs. Certainly, one of the reasons for these changes was due to organizational changes in the working of the entire health system due to the COVID-19 pandemic.

Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol

BACKGROUND

The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been widely used in practice and research to evaluate health service quality and efficiency worldwide. The definition of ACSCs varies across countries due to different challenges posed on healthcare systems. However, China does not have its own list of ACSCs. The study aims to develop a list to meet health system monitoring, reporting and evaluation needs in China.

METHODS

To develop the list, we will combine the best methodological evidence available with real-world evidence, adopt a systematic and rigorous process and absorb multidisciplinary expertise. Specific steps include: (1) establishment of working groups; (2) generations of the initial list (review of already published lists, semi-structured interviews, calculations of hospitalization rate); (3) optimization of the list (evidence evaluation, Delphi consensus survey); and (4) approval of a final version of China's ACSCs list. Within each step of the process, we will calculate frequencies and proportions, use descriptive analysis to summarize and draw conclusions, discuss the results, draft a report, and refine the list.

DISCUSSION

Once completed, China's list of ACSCs can be used to comprehensively evaluate the current situation and performance of health services, identify flaws and deficiencies embedded in the healthcare system to provide evidence-based implications to inform decision-makings towards the optimization of China's healthcare system. The experiences might be broadly applicable and serve the purpose of being a prime example for nations with similar conditions.

Preadmission morbidity and healthcare utilization among older adults with potentially avoidable hospitalizations: a Danish case-control study

PURPOSE

Examine preadmission diagnoses, medication use, and preadmission healthcare utilization among older adults prior to first potentially avoidable hospitalizations.

METHODS

A nationwide population-based case-control study using Danish healthcare data. All Danish adults aged ≥ 65 years who had a first potentially avoidable hospitalization from January 1995 through March 2019 (n = 725,939) were defined as cases, and 1:1 age- and sex-matched general population controls (n = 725,939). Preadmission morbidity and healthcare utilization were assessed based on a complete hospital diagnosis history within 10 years prior, and all medication use and healthcare contacts 1 year prior. Using log-binomial regression, we calculated adjusted prevalence ratios (PR) with 95% confidence intervals (CI).

RESULTS

Included cases and controls had a median age of 78 years and 59% were female. The burden of preadmission morbidity was higher among cases than controls. The strongest associations were observed for preadmission chronic lung disease (PR 3.8, CI 3.7-3.8), alcohol-related disease (PR 3.1, CI 3.0-3.2), chronic kidney disease (PR 2.4, CI 2.4-2.5), psychiatric disease (PR 2.2, CI 2.2-2.3), heart failure (PR 2.2, CI 2.2-2.3), and previous hospital contacts with infections (PR 2.2, CI 2.2-2.3). A high and accelerating number of healthcare contacts was observed during the months preceding the potentially avoidable hospitalization (having over 5 GP contacts 1 month prior, PR 3.0, CI 3.0-3.0).

CONCLUSION

A high number of healthcare contacts and preadmission morbidity and medication use, especially chronic lung, heart, and kidney disease, alcohol-related or psychiatric disease including dementia, and previous infections are strongly associated with potentially avoidable hospitalizations.

Variations in the intended utilization of emergency care in case of gastrointestinal diseases

Frequent utilization of emergency care and overcrowded emergency departments (EDs) are highly relevant topics due to their harmful consequences for patients and staff. The present study examines variations of intended health care use in urgent and non-urgent cases among the general population. In a cross-sectional telephone survey, a sample of N = 1,204 adults residing in Hamburg, Germany, was randomly drawn. At the beginning of the survey, one of 24 different vignettes (case stories) describing symptoms of inflammatory gastrointestinal diseases were presented to the participants. The vignettes varied in sex (male/female), age (15, 49, 72 years), daytime (Tuesday morning, Tuesday evening), and urgency (low, high). Participants were asked in an open-ended question about their primal intended utilization if they or their children would be affected by such symptoms. Overall, about 14 % chose emergency facilities (ED, ambulance, emergency practice) despite presentation of non-urgent conditions (n = 602). Intended emergency care use varied considerably even if the degree of urgency was comparable. Adolescence, male sex, and symptoms occurring in the evening were associated with increased ED and ambulance use. Inappropriate utilization of ED and ambulance (analyses regarding utilization due to non-urgent problems) was more often observed among male respondents and those with a migration background (1st generation). Information campaigns focused on emergency care use and reorganisation of emergency care wards are possible interventions.

Healthcare costs for legally adjudicated elder mistreatment victims in comparison to non-mistreated older adults

BACKGROUND

Elder mistreatment (EM) is associated with adverse health outcomes and healthcare utilization patterns that differ from other older adults. However, the association of EM with healthcare costs has not been examined. Our goal was to compare healthcare costs between legally adjudicated EM victims and controls.

METHODS

We used Medicare insurance claims to examine healthcare costs of EM victims in the 2 years surrounding initial mistreatment identification in comparison to matched controls. We adjusted costs using the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) risk score.

RESULTS

We examined healthcare costs in 114 individuals who experienced EM and 410 matched controls. Total Medicare Parts A and B healthcare costs were similar between cases and controls in the 12 months prior to initial EM detection ($11,673 vs. $11,402, p = 0.92), but cases had significantly higher total healthcare costs during the 12 months after initial mistreatment identification ($15,927 vs. $10,805, p = 0.04). Adjusting for CMS-HCC scores, cases had, in the 12 months after initial EM identification, $5084 of additional total healthcare costs (95% confidence interval [$92, $10,077], p = 0.046) and $5817 of additional acute/subacute/post-acute costs (95% confidence interval [$1271, $10,362], p = 0.012) compared with controls. The significantly higher total costs and acute/sub-acute/post-acute costs among EM victims in the post-year were concentrated in the 120 days after EM detection.

CONCLUSIONS

Older adults experiencing EM had substantially higher total costs during the 12 months after mistreatment identification, driven by an increase in acute/sub-acute/post-acute costs and focused on the period immediately after initial EM detection.

The effect of primary healthcare on mortality: Evidence from Costa Rica

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Study protocol of a randomized controlled trial to assess safety of teleconsultation compared with face-to-face consultation: the ECASeT study

BACKGROUND

The use of remote consultation modalities has exponentially grown in the past few years, particularly since the onset of the COVID-19 pandemic. Although a huge body of the literature has described the use of phone (tele) and video consultations, very few of the studies correspond to randomized controlled trials, and none of them has assessed the safety of these consultation modalities as the primary objective. The primary objective of this trial was to assess the safety of remote consultations (both video and teleconsultation) in the follow-up of patients in the hospital setting.

METHODS

Multicenter, randomized controlled trial being conducted in four centers of an administrative healthcare area in Catalonia (North-East Spain). Participants will be screened from all individuals, irrespective of age and sex, who require follow-up in outpatient consultations of any of the departments involved in the study. Eligibility criteria have been established based on the local guidelines for screening patients for remote consultation. Participants will be randomly allocated into one of the two study arms: conventional face-to-face consultation (control) and remote consultation, either teleconsultation or video consultation (intervention). Routine follow-up visits will be scheduled at a frequency determined by the physician based on the diagnostic and therapy of the baseline disease (the one triggering enrollment). The primary outcome will be the number of adverse reactions and complications related to the baseline disease. Secondary outcomes will include non-scheduled visits and hospitalizations, as well as usability features of remote consultations. All data will either be recorded in an electronic clinical report form or retrieved from local electronic health records. Based on the complications and adverse reaction rates reported in the literature, we established a target sample size of 1068 participants per arm. Recruitment started in May 2022 and is expected to end in May 2024.

DISCUSSION

The scarcity of precedents on the assessment of remote consultation modalities using randomized controlled designs challenges making design decisions, including recruitment, selection criteria, and outcome definition, which are discussed in the manuscript.

TRIAL REGISTRATION

NCT05094180. The items of the WHO checklist for trial registration are available in Additional file 1. Registered on 24 November 2021.

Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany

Increasing emergency department (ED) utilization induces considerable pressure on ED staff and organization in Germany. Reasons for certain ED attendances are seen partly in insufficient continuity of care outside of hospitals. To explore the health care patterns before and after an ED attendance in Germany, we used claims data from nine statutory health insurance funds, covering around 25 % of statutory health insurees (1). We descriptively analyzed ED attendances for adult patients in 2016 according to their sociodemographic characteristics and diagnoses (2). Based on the ED attendance as initial event, we investigated health care provider utilization 180 days before and after the respective ED treatment and are presented by means of Sankey diagrams. In total, 4,757,536 ED cases of 3,164,343 insured individuals were analyzed. Back pain was the most frequent diagnosis in outpatient ED cases (5.0 %), and 80.2 % of the patients visited primary care physicians or specialists 180 days before and 78.8 % 180 days after ED treatment. Among inpatient cases, heart failure (4.6 %) was the leading diagnosis and 74.6 % used primary care physicians or specialists 180 days before and 65.1 % 180 days after ED treatment. The ED re-attendance slightly increased for back pain (4.9 % to 7.9 %) and decreased for heart failure (13.4 % to 12.6 %).

Changing inequity in health service utilization and financial burden among patients with hypertension in China: evidence from China Health and Retirement Longitudinal Study (CHARLS), 2011-2018

BACKGROUND

China initiated a health system reform in 2009 to achieve Universal Health Coverage (UHC) by 2020. While the effectiveness of health-system reforms has been studied, equity in health-service utilization and financial burden remains underexplored. This study evaluated whether the health system reform has improved the equity in utilization and financial burden of health services among patients with hypertension in China.

METHODS

We obtained data from four waves of the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. The main outcome variables were outpatient and inpatient service utilization rates and catastrophic health expenditure (CHE) for patients with hypertension. The Standardized Concentration Index (CI) was used to measure the changing equity in health service utilization and affordability.

RESULTS

Outpatient service utilization was relatively equal among patients with varying socioeconomic statuses (SESs) (CI: 0.041 in 2011 and 0.064 in 2018). Inpatient service utilization inequity improved from CI 0.144 in 2011 to CI 0.066 in 2018. CHE incidence increased from 15.6% in 2011 to 24.2% in 2018. CI for CHE declined from -0.069 in 2011 to -0.012 in 2015 but increased to -0.063 in 2018.

CONCLUSIONS

Health insurance expansion and poverty alleviation policies promoted equity in inpatient service utilization for hypertensive patients. However, the financial burden for the poor requires further attention through reimbursement policy adjustments for outpatient services in primary care settings.

Severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions among the UK Biobank cohort

BACKGROUND

People with mental disorders have worse physical health compared with the general population, which could be attributable to receiving poorer quality healthcare.

AIMS

To examine the relationship between severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions (ACSCs), and factors associated with increased risk.

METHOD

Baseline data for England (N = 445 814) were taken from UK Biobank, which recruited participants aged 37-73 years during 2006-2010, and linked to hospital admission records up to 31 December 2019. Participants were grouped into those with a history of either schizophrenia, bipolar disorder, depression or anxiety, or no mental disorder. Survival analysis was used to assess the risk of hospital admission for ACSCs among those with mental disorders compared with those without, adjusting for factors in different domains (sociodemographic, socioeconomic, health and biomarkers, health-related behaviours, social isolation and psychological).

RESULTS

People with schizophrenia had the highest (unadjusted) risk of hospital admission for ACSCs compared with those with no mental disorder (hazard ratio 4.40, 95% CI 4.04-4.80). People with bipolar disorder (hazard ratio 2.48, 95% CI 2.28-2.69) and depression or anxiety (hazard ratio 1.76, 95% CI 1.73-1.80) also had higher risk. Associations were more conservative when including all admissions, as opposed to first admissions only. The observed associations persisted after adjusting for a range of factors.

CONCLUSIONS

People with severe mental disorders have the highest risk of preventable hospital admissions. Ensuring people with mental disorders receive adequate ambulatory care is essential to reduce the large health inequalities they experience.

Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers

BACKGROUND

Public assistance programs aim to prevent financial poverty by guaranteeing a minimum income for basic needs, including medical care. However, time poverty also matters, especially in the medical care adherence of people with chronic diseases. This study aimed to examine the association between the dual burden of working and household responsibilities, with unscheduled asthma care visits among public assistance recipients in Japan.

METHODS

This retrospective cohort study included public assistance recipients from two municipalities. We obtained participants' sociodemographic data in January 2016 from the public assistance database and identified the incidence of asthma care visits. Participants' unscheduled asthma visits and the frequency of asthma visits were used as the outcome variables. Unscheduled visits were defined as visits by recipients who did not receive asthma care during the first three months of the observation period. Participants' age, sex, household composition, and work status were used as explanatory variables. Multiple Poisson regression analyses were performed to calculate the cumulative incidence ratio (IR) with a 95% confidence interval (CI) of unscheduled visits across the explanatory variables. The effect of modification on the work status by household composition was also examined.

RESULTS

We identified 2,386 recipients at risk of having unscheduled visits, among which 121 patients (5.1%) had unscheduled visits. The multivariable Poisson regression revealed that the working recipients had a higher incidence of unscheduled visits than the non-working recipients (IR 1.44, 95% CI 1.00-2.07). Among working recipients, the IRs of unscheduled visits were higher among recipients cohabiting with adults (IR 1.90 95% CI 1.00-3.59) and with children (IR 2.35, 95% CI 1.11-4.95) than for recipients living alone. Among non-working recipients, the IRs of unscheduled visits were lower for recipients living with family (IR 0.74, 95% CI 0.41-1.35) and those living with children (IR 0.50, 95% CI 0.20-1.23). A higher frequency in asthma visits was observed among working recipients living with family.

CONCLUSIONS

Working adults cohabiting with children are at the greatest risk of unscheduled visits among adults receiving public assistance. To support healthy lifestyles of public assistance recipients, medical care providers and policymakers should pay special attention to the potentially underserved populations.

National Norms for Hospitalizations Due to Ambulatory Care Sensitive Conditions among Adults in the US

BACKGROUND

Ambulatory care sensitive conditions (ACSCs) are acute or chronic health issues that lead to potentially preventable hospitalizations when not treated in the outpatient primary care setting.

OBJECTIVE

To describe national hospitalization rates due to ACSCs among adult inpatients in the US.

DESIGN

A retrospective cross-sectional analysis of the 2018 US National Inpatient Sample (NIS) dataset from the Healthcare Cost and Utilization Project at the Agency of Healthcare Research and Quality was completed in the year 2022.

PARTICIPANTS

Participants were adult inpatients from community hospitals in 48 states of the US and District of Columbia.

MAIN MEASURES

ACSC admission rates were calculated using ICD-10 codes and the Purdy ACSC definition. The admission rates were weighted to the US inpatient population and stratified by age, sex, and race.

KEY RESULTS

ACSC hospitalization rates varied considerably across age and average number of hospitalizations varied across sex and race. ACSC hospitalization rates increased with age, male sex, and Native American and Black race. The most common ACSCs were pneumonia, diabetes, and congestive heart failure.

CONCLUSIONS

Previous studies have emphasized the importance of preventable hospitalizations, however, the national rates for ACSC hospitalizations across all ages in the US have not been reported. The national rates presented will facilitate comparisons to identify hospitals and health care systems with higher-than-expected rates of ACSC admissions that may suggest a need for improved primary care services.

Interrupted time series evaluation of the impact of a dementia wellbeing service on avoidable hospital admissions for people with dementia in Bristol, England

OBJECTIVES

To determine whether a dementia wellbeing service (DWS) signposting people with dementia to community services decreases the rate of avoidable hospital admissions, in-hospital mortality, complexity of admissions (number of comorbidities) or length of stay.

METHODS

Interrupted time series analysis to estimate the effects of the DWS on hospital outcomes. We included all unplanned admissions for ambulatory care sensitive conditions ('avoidable hospital admissions') with a dementia diagnosis recorded in the Hospital Episode Statistics. The intervention region was compared with a demographically similar control region in the 2 years before and 3 years after the implementation of the new service (October 2013 to September 2018).

RESULTS

There was no strong evidence that admission rates reduced and only weak evidence that the trend in average length of stay reduced slowly over time. In-hospital mortality decreased immediately after the introduction of the dementia wellbeing service compared to comparator areas (x0.64, 95% CI 0.42, 0.97, p = 0.037) but attenuated over the following years. The rate of increase in comorbidities also appeared to slow after the service began; they were similar to comparator areas by September 2018.

CONCLUSIONS

We found no major impact of the DWS on avoidable hospital admissions, although there was weak evidence for slightly shorter length of stay and reduced complexity of hospital admissions. These findings may or may not reflect a true benefit of the service and require further investigation. The DWS was established to improve quality of dementia care; reducing hospital admissions was never its sole purpose. More targeted interventions may be required to reduce hospital admissions for people with dementia.

The incidence rate of planned and emergency physical health hospital admissions in people diagnosed with severe mental illness: a cohort study

BACKGROUND

People with severe mental illness (SMI) have more physical health conditions than the general population, resulting in higher rates of hospitalisations and mortality. In this study, we aimed to determine the rate of emergency and planned physical health hospitalisations in those with SMI, compared to matched comparators, and to investigate how these rates differ by SMI diagnosis.

METHODS

We used Clinical Practice Research DataLink Gold and Aurum databases to identify 20,668 patients in England diagnosed with SMI between January 2000 and March 2016, with linked hospital records in Hospital Episode Statistics. Patients were matched with up to four patients without SMI. Primary outcomes were emergency and planned physical health admissions. Avoidable (ambulatory care sensitive) admissions and emergency admissions for accidents, injuries and substance misuse were secondary outcomes. We performed negative binomial regression, adjusted for clinical and demographic variables, stratified by SMI diagnosis.

RESULTS

Emergency physical health (aIRR:2.33; 95% CI 2.22-2.46) and avoidable (aIRR:2.88; 95% CI 2.60-3.19) admissions were higher in patients with SMI than comparators. Emergency admission rates did not differ by SMI diagnosis. Planned physical health admissions were lower in schizophrenia (aIRR:0.80; 95% CI 0.72-0.90) and higher in bipolar disorder (aIRR:1.33; 95% CI 1.24-1.43). Accident, injury and substance misuse emergency admissions were particularly high in the year after SMI diagnosis (aIRR: 6.18; 95% CI 5.46-6.98).

CONCLUSION

We found twice the incidence of emergency physical health admissions in patients with SMI compared to those without SMI. Avoidable admissions were particularly elevated, suggesting interventions in community settings could reduce hospitalisations. Importantly, we found underutilisation of planned inpatient care in patients with schizophrenia. Interventions are required to ensure appropriate healthcare use, and optimal diagnosis and treatment of physical health conditions in people with SMI, to reduce the mortality gap due to physical illness.

Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan

BACKGROUND

To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life.

METHODS

A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis.

RESULTS

The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics.

CONCLUSIONS

HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.

In-Hospital Deaths From Ambulatory Care-Sensitive Conditions Before and During the COVID-19 Pandemic in Japan

Importance

The COVID-19 pandemic may have played a role in the deterioration of access to medical care for ambulatory care-sensitive conditions (ACSCs).

Objective

To ascertain whether the number of in-hospital deaths and in-hospital mortality rate associated with ACSC changed after the declaration of the COVID-19 national state of emergency in Japan.

Design, Setting, and Participants

This cohort study used a difference-in-differences design to compare outcomes for ACSC in the period before (January 1, 2015, to December 31, 2019) vs the period after (January 1, 2020, to December 31, 2020) Japan declared a national state of emergency for the COVID-19 pandemic. Analyses used discharge summary data from 242 acute care hospitals across Japan. The sample comprised unscheduled hospitalizations of patients with ACSC during the study period (January 1, 2015, to December 31, 2020). Data analyses were performed between August 16 and December 7, 2022.

Exposure

The declaration of the COVID-19 national state of emergency announced by the Japanese government in April 2020 was considered to be an exogenous shock.

Main Outcomes and Measures

Primary outcomes were the ACSC-associated number of in-hospital deaths, number of hospitalizations, and in-hospital mortality rate.

Results

A total of 28 321 ACSC-related hospitalizations were observed involving 15 318 males (54.1%), with a median (IQR) age of 76 (58-85) years. The number of in-hospital deaths was 2117 (7.5%). The number of hospitalizations decreased overall (incidence rate ratio [IRR], 0.84; 95% CI, 0.75-0.94), for chronic conditions (IRR, 0.84; 95% CI, 0.77-0.92), and for vaccine-preventable conditions (IRR, 0.58; 95% CI, 0.44-0.76). However, in-hospital deaths (IRR, 1.66; 95% CI, 1.15-2.39) and in-hospital deaths within 24 hours of hospital arrival (IRR, 7.27 × 106; 95% CI, 1.83 × 106 to 2.89 × 107) increased for acute conditions. The in-hospital mortality rate increased for acute conditions (IRR, 1.71; 95% CI, 1.16-2.54), and the 24-hour in-hospital mortality rates also increased overall (IRR, 1.87; 95% CI, 1.19-2.96), for acute conditions (IRR, 2.15 × 106; 95% CI, 5.25 × 105 to 8.79 × 106), and for vaccine-preventable conditions (IRR, 4.64; 95% CI, 1.28-16.77).

Conclusions and Relevance

This cohort study found that in Japan, the number of in-hospital deaths increased after the declaration of the COVID-19 national state of emergency in 2020, particularly for acute ACSC and deaths within 24 hours of hospital admission. This finding suggests that access to good-quality primary care and inpatient care for patients with acute ACSC may have been compromised during the pandemic.

Does the immediate reimbursement of medical insurance reduce the socioeconomic inequality in health among the floating population? Evidence from China

BACKGROUND

Enhancing health intervention for floating populations has become an essential aspect of public health around the world. China launched a policy reform aimed at implementing immediate reimbursement for trans-provincial inpatient treatments. The objective of this study was to investigate the effects of this policy change on socioeconomic inequality in health among the floating population.

METHODS

This study used two waves of individual-level data from the China Migrants Dynamic Survey (CMDS) collected in 2017 and 2018 as well as administrative hospital data at the city level. The sample included 122061 individuals and 262 cities. Under a quasi-experimental research design, we built up the framework to employ the generalized and multi-period difference-in-differences estimation strategy. We used the number of qualified hospitals that could provide immediate reimbursement to represent the degree and intensity of the implementation of this policy change. We also calculated the Wagstaff Index (WI) to measure socioeconomic inequality in health.

RESULTS

This policy change and income level had a negative joint impact on the health status of floating population (odds ratio = 0.955, P < 0.01), that is, the lower the income, the better the number of qualified hospitals' effect on health improvement. Furthermore, as the number of qualified tertiary hospitals increased, the health inequality would decrease significantly on average at the city level (P < 0.05). In addition, inpatient utilization as well as total expenditure and reimbursement significantly improved after the policy change, and the magnitude of increase was greater in the relatively lower-income group (P < 0.01). Finally, only inpatient spending could obtain immediate reimbursement in the early stage, thus, compared with primary care, these impacts were greater in tertiary care.

CONCLUSIONS

Our study revealed that after the implementation of immediate reimbursement, the floating population could obtain greater and more timely reimbursement, which significantly increased its inpatient utilization, promoted health, and reduced the health inequality caused by socioeconomic factors. These results suggest that a more accessible and friendly medical insurance scheme should be promoted for this group.

Hospital-associated disability due to avoidable hospitalizations among older adults

BACKGROUND

Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses.

METHODS

We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults ≥ 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations.

RESULTS

We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services.

CONCLUSIONS

Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis

OBJECTIVE

This study aimed to examine the clinical capability of township healthcare centres (THCs), the main primary care providers in rural China, as a basis for rural health service planning.

DESIGN

Observational study of quantitative analysis using administrative data.

SETTING

Three counties with low, middle and high social economic development level, respectively, in Sichuan province western China.

PARTICIPANTS

9 THCs and 6 county hospitals (CHs) were purposively selected in the three counties. Summary of electronic medical records of 31 633 admissions from 1 January 2015 to 30 December 2015 of these selected health institutions was obtained from the Health Information Centre of Sichuan province.

MAIN OUTCOME MEASURES

Six indicators in scope of inpatient services related to diseases and surgeries in the THCs as proxy of clinical capability, were compared against national standard of capability building of THCs, among counties, and between THCs and CHs of each county.

RESULTS

The clinical capability of THCs was suboptimal against the national standard, though that of the middle-developed county was better than that in the rich and the poor counties. THCs mainly provided services of infectious or inflammatory diseases, of respiratory and digestive systems, but lacked clinical services related to injuries, poisoning, pregnancy, childbirth and surgeries. A large proportion of the top 20 diseases of inpatients were potentially avoidable hospitalisations (PAHs) and were overlapped between THCs and CHs.

CONCLUSIONS

The clinical capability of THCs was generally suboptimal against national standard. It may be affected by the economics, population size, facilities, workforce and the share of services of THCs in local health systems. Identification of absent services and PAHs may help to identify development priorities of local THCs. Clarification of the roles of THCs and CHs in the tiered rural health system in China is warranted to develop a better integrated health system.

The Impact of the Swedish Care Coordination Act on Hospital Readmission and Length-of-Stay among Multi-Morbid Elderly Patients: A Controlled Interrupted Time Series Analysis

Coordinating follow-up care after discharge from hospital is critical to ensuring good outcomes for patients, but is difficult when multiple care providers are involved. In 2018, Sweden adopted the Care Coordination Act, which modified economic incentives to reduce discharge delays and mandated a discharge planning process for patients requiring post-discharge social- or primary care services. This study evaluates the impact of this reform on hospital length-of-stay and unplanned readmissions among multi-morbid elderly patients. Interrupted time series analysis of all in-patient care episodes involving multi-morbid elderly patients in Sweden from 2015 - 2019 (n = 2 386 039) was performed. Secondary analyses using case-mix adjustment and controlled interrupted time series analysis were employed to assess for bias. Average length of stay decreased during the post-reform period, corresponding to 248 521 saved care days. Unplanned readmissions meanwhile increased, corresponding to 7 572 excess unplanned readmissions. While reductions in length-of-stay were concentrated among patients targeted by the reform, increases in readmission rates were similar in patients not targeted by the reform, indicating potential confounding. The reform thus appears to have achieved its goal of decreasing in-patient length of stay, but a robust effect on readmissions, outpatient visits, or mortality was not found. This may be due to lackluster implementation or an ineffective mandated intervention.

Using Explainable Artificial Intelligence to Predict Potentially Preventable Hospitalizations: A Population-Based Cohort Study in Denmark

BACKGROUND

The increasing aging population and limited health care resources have placed new demands on the healthcare sector. Reducing the number of hospitalizations has become a political priority in many countries, and special focus has been directed at potentially preventable hospitalizations.

OBJECTIVES

We aimed to develop an artificial intelligence (AI) prediction model for potentially preventable hospitalizations in the coming year, and to apply explainable AI to identify predictors of hospitalization and their interaction.

METHODS

We used the Danish CROSS-TRACKS cohort and included citizens in 2016-2017. We predicted potentially preventable hospitalizations within the following year using the citizens' sociodemographic characteristics, clinical characteristics, and health care utilization as predictors. Extreme gradient boosting was used to predict potentially preventable hospitalizations with Shapley additive explanations values serving to explain the impact of each predictor. We reported the area under the receiver operating characteristic curve, the area under the precision-recall curve, and 95% confidence intervals (CI) based on five-fold cross-validation.

RESULTS

The best performing prediction model showed an area under the receiver operating characteristic curve of 0.789 (CI: 0.782-0.795) and an area under the precision-recall curve of 0.232 (CI: 0.219-0.246). The predictors with the highest impact on the prediction model were age, prescription drugs for obstructive airway diseases, antibiotics, and use of municipality services. We found an interaction between age and use of municipality services, suggesting that citizens aged 75+ years receiving municipality services had a lower risk of potentially preventable hospitalization.

CONCLUSION

AI is suitable for predicting potentially preventable hospitalizations. The municipality-based health services seem to have a preventive effect on potentially preventable hospitalizations.

Who are the most vulnerable populations for primary care? Avoidable hospitalizations across individuals with different types of disabilities in South Korea

BACKGROUND

Individuals with disabilities have limited access to primary care, the quality of care must be examined.

OBJECTIVE

To examine avoidable hospitalizations among individuals with disabilities and determine the most vulnerable populations across types of disabilities.

METHODS

Using the Korean National Health Insurance Claims Database, we compared hypertension- and diabetes-related avoidable hospitalizations (HRAH and DRAH, respectively) across disability status and disability type based on age-sex standardized rates from 2011 to 2020 and logistic regression.

RESULTS

The gap between those with and without disabilities in age-sex standardized HRAH and DRAH increased over 10 years. Odds ratios for HRAH were higher for those with disabilities, with individuals with mental disabilities having the highest odds ratio, followed by those with intellectual/developmental disabilities, then those with physical disabilities; for DRAH, the three highest odds ratios belonged to individuals with mental, intellectual/developmental, and visual disabilities. Among those with disabilities, HRAH was higher for those with mental, intellectual/developmental, and severe physical disabilities, whereas DRAH was higher for those with mental, severe visual, and intellectual/developmental disabilities compared to those with mild physical disabilities.

CONCLUSION

This study reveals high avoidable hospitalization rates among individuals with disabilities and calls for policies supporting quality primary care and comprehensively addressing disparities.

Evaluating emergency department transfers from urgent care centres: insights for paramedic integration with subacute healthcare

OBJECTIVE

Paramedics redirecting non-emergent patients from emergency departments (EDs) to urgent care centres is a new and forthcoming strategy to reduce overcrowding and improve primary care integration. Which patients are likely not suitable for paramedic redirection are unknown. To describe and specify patients inappropriate for urgent care centres, we examined associations between patient characteristics and transfer to the ED after patients initially presented to an urgent care centre.

METHODS

A population-based retrospective cohort study of all adult (≥18 years) visits to an urgent care centre from 1 April 2015 to 31 March 2020 in Ontario, Canada. Binary logistic regression was used to determine unadjusted and adjusted associations between patient characteristics and being transferred to an ED using OR and 95% CIs. We calculated the absolute risk difference for the adjusted model.

RESULTS

A total of 1 448 621 urgent care visits were reported, with 63 343 (4.4%) visits transferred to an ED for definitive care. Being 65 years and older (OR 2.29, 95% CI 2.23 to 2.35), scored an emergent Canadian Triage and Acuity Scale of 1 or 2 (OR 14.27, 95% CI 13.45 to 15.12) and higher comorbidity count (OR 1.51, 95% CI 1.46 to 1.58) had added odds of association with being transferred out to an ED.

CONCLUSION

Readily available patient characteristics were independently associated with interfacility transfers between urgent care centres and the ED. This study can support paramedic redirection protocol development, highlighting which patients may not be best suited for ED redirection.

Primary and secondary data in emergency medicine health services research - a comparative analysis in a regional research network on multimorbid patients

BACKGROUND

This analysis addresses the characteristics of two emergency department (ED) patient populations defined by three model diseases (hip fractures, respiratory, and cardiac symptoms) making use of survey (primary) and routine (secondary) data from hospital information systems (HIS). Our aims were to identify potential systematic inconsistencies between both data samples and implications of their use for future ED-based health services research.

METHODS

The research network EMANET prospectively collected primary data (n=1442) from 2017-2019 and routine data from 2016 (n=9329) of eight EDs in a major German city. Patient populations were characterized using socio-structural (age, gender) and health- and care-related variables (triage, transport to ED, case and discharge type, multi-morbidity). Statistical comparisons between descriptive results of primary and secondary data samples for each variable were conducted using binomial test, chi-square goodness-of-fit test, or one-sample t-test according to scale level.

RESULTS

Differences in distributions of patient characteristics were found in nearly all variables in all three disease populations, especially with regard to transport to ED, discharge type and prevalence of multi-morbidity. Recruitment conditions (e.g., patient non-response), project-specific inclusion criteria (e.g., age and case type restrictions) as well as documentation routines and practices of data production (e.g., coding of diagnoses) affected the composition of primary patient samples. Time restrictions of recruitment procedures did not generate meaningful differences regarding the distribution of characteristics in primary and secondary data samples.

CONCLUSIONS

Primary and secondary data types maintain their advantages and shortcomings in the context of emergency medicine health services research. However, differences in the distribution of selected variables are rather small. The identification and classification of these effects for data interpretation as well as the establishment of monitoring systems in the data collection process are pivotal.

TRIAL REGISTRATION

DRKS00011930 (EMACROSS), DRKS00014273 (EMAAGE), NCT03188861 (EMASPOT).

[Nursing home-sensitive conditions and approaches to reduce hospitalization of nursing home residents]

BACKGROUND

Interventions to reduce potentially risky hospitalizations among nursing home residents are highly relevant for patient safety and quality improvement. A catalog of nursing home-sensitive conditions (NHSCs) grounds the policy recommendations and interventions.

METHODS

In two previous research phases, an expert panel developed a catalog of 58 NHSCs using an adapted Delphi-procedure (the RAND/UCLA Appropriateness Method). This procedure was developed by the North American non-profit Research and Development Organisation (RAND) and clinicians of the University of California in Los Angeles (UCLA). We present the third phase of the project focused on the development of interventions to reduce NHSCs starting with an expert workshop. The workshop results were then evaluated by six experts from related sectors, supplemented, and systematically used to produce recommendations for action. Possible implementation obstacles were considered and the time horizon of effectiveness was estimated.

RESULTS

The recommendations address communication, cooperation, documentation and care competence as well as facility-related, financial, and legal aspects. Indication bundles demonstrate the relevance for the German healthcare system. To increase effectiveness, the experts advise a meaningful combination of individual recommendations.

DISCUSSION

By optimizing multidisciplinary communication and cooperation, combined with an- also digital - expansion of the infrastructure and the creation of institution-specific and legal prerequisites as well as remuneration structures, an estimated 35% of all hospitalizations, approximately 220,000 hospitalizations for Germany, could be prevented. The implementation expenditure could be refinanced by avoided hospitalization savings amounting to 768 million euros.

Emergency Department and Hospital Utilization Among Older Adults Before and After Identification of Elder Mistreatment

Importance

Elder mistreatment is common and has serious health consequences. Little is known, however, about patterns of health care utilization among older adults experiencing elder mistreatment.

Objective

To examine emergency department (ED) and hospital utilization of older adults experiencing elder mistreatment in the period surrounding initial mistreatment identification compared with other older adults.

Design, Setting, and Participants

This retrospective case-control study used Medicare insurance claims to examine older adults experiencing elder mistreatment initially identified between January 1, 2003, and December 31, 2012, and control participants matched on age, sex, race and ethnicity, and zip code. Statistical analysis was performed in April 2022.

Main Outcomes and Measures

We used multiple measures of ED and hospital utilization patterns (eg, new and return visits, frequency, urgency, and hospitalizations) in the 12 months before and after mistreatment identification. Data were adjusted using US Centers for Medicare and Medicaid Services Hierarchical Condition Categories risk scores. Chi-squared tests and conditional logistic regression models were used for data analyses.

Results

This study included 114 case patients and 410 control participants. Their median age was 72 years (IQR, 68-78 years), and 340 (64.9%) were women. Race and ethnicity were reported as racial or ethnic minority (114 [21.8%]), White (408 [77.9%]), or unknown (2 [0.4%]). During the 24 months surrounding identification of elder mistreatment, older adults experiencing mistreatment were more likely to have had an ED visit (77 [67.5%] vs 179 [43.7%]; adjusted odds ratio [AOR], 2.95 [95% CI, 1.78-4.91]; P < .001) and a hospitalization (44 [38.6%] vs 108 [26.3%]; AOR, 1.90 [95% CI, 1.13-3.21]; P = .02) compared with other older adults. In addition, multiple ED visits, at least 1 ED visit for injury, visits to multiple EDs, high-frequency ED use, return ED visits within 7 days, ED visits for low-urgency issues, multiple hospitalizations, at least 1 hospitalization for injury, hospitalization at multiple hospitals, and hospitalization for ambulatory care sensitive conditions were substantially more likely for individuals experiencing elder mistreatment. The rate of ED and hospital utilization for older adults experiencing elder mistreatment was much higher in the 12 months after identification than before, leading to more pronounced differences between case patients and control participants in postidentification utilization. During the 12 months after identification of elder mistreatment, older adults experiencing mistreatment were particularly more likely to have had high-frequency ED use (12 [10.5%] vs 8 [2.0%]; AOR, 8.23 [95% CI, 2.56-26.49]; P < .001) and to have visited the ED for low-urgency issues (12 [10.5%] vs 8 [2.0%]; AOR, 7.33 [95% CI, 2.54-21.18]; P < .001).

Conclusions and Relevance

In this case-control study of health care utilization, older adults experiencing mistreatment used EDs and hospitals more frequently and with different patterns during the period surrounding mistreatment identification than other older adults. Additional research is needed to better characterize these patterns, which may be helpful in informing early identification, intervention, and prevention of elder mistreatment.

Potentially avoidable hospitalizations for older patients transferred from long-term care hospitals: a nationwide cross-sectional analysis of potential healthcare consequences

Multiple chronic disorders and disabilities among older patients in long term care hospitals (LTCH) tends to increase the healthcare burden by causing overcrowding, particularly in emergency departments. Therefore, access to timely and adequate healthcare for LTCH patients is an increasingly important issue, and potentially avoidable hospitalizations (PAHs) and hospitalizations during non-office hours can result as indicators of emergency department overcrowding. The study aimed to evaluate PAHs and hospitalizations during non-office hours in emergency departments for older patients transferred from LTCH compared to patients living at home. We performed a cross-sectional study using the National Emergency Department Information System database from January 2018 to December 2019, in South Korea, with older patients (≥ 65 years) who visited nationwide emergency departments. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for indicators of overcrowding as PAHs and hospitalizations during non-office hours were calculated by logistic regression. Among the 2,177,663 older patients who visited the emergency departments, 98,434 patients were living in LTCH and 2,079,229 patients were living at home. The older patients living in LTCH was associated with PAHs (aOR: 1.90, 95% CI 1.87-1.94) and hospitalizations during non-office hours (aOR: 1.76, 95% CI 1.73-1.78). LTCH patients showed more hospital visits, extended stay in the emergency department, greater prevalence of chronic diseases, greater rates of transfer as well as higher admission rates and mortality as compared to the patients living at home. The LTCH older patients were associated with the indicators of emergency department overcrowding, which impacts health care quality in hospitals. Introduction of policy and training programs for LTCH staff are recommended to manage vulnerable groups in advance.

Examining the "Potentially Preventable Emergency Department Transfer" Indicator Among Nursing Home Residents

OBJECTIVE

To determine if nursing home (NH) resident characteristics associated with potentially preventable emergency department transfers (PPEDs) are similarly associated with non-potentially preventable emergency department transfers (non-PPEDs).

DESIGN

We conducted a population-level retrospective cohort study using linked administrative data reported using the Resident Assessment Instrument-Minimum Data Set Version 2.0 and the National Ambulatory Care Reporting System for emergency department transfers.

SETTING AND PARTICIPANTS

We assessed all NH residents transferred to the emergency department within 92 days after admission. The cohort included 56,433 NH resident admissions assessment of which 3498 NH residents experienced PPEDs, and 9331 residents experienced non-PPEDs.

METHODS

We assessed Ontario NH residents admission assessments collected between January 1, 2017, and December 31, 2018. We used cumulative incidence functions and Cox regression to compare resident characteristics between residents experiencing PPEDs and non-PPEDs. PPEDs were defined based on the International Classification of Diseases, 10th Revision.

RESULTS

Approximately 23% of residents experienced an emergency department transfer within 92 days of NH admission. The cumulative incidence of PPEDs was 6.3% and non-PPEDs was 16.8%. After adjusting for clinically relevant features, 14 of 18 resident admission characteristics were associated with both types of transfers. Resident admission characteristics associated with a greater risk of PPEDs solely were pneumonia [hazard ratio (HR) 1.48; CI 1.25-1.70] and oxygen therapy (HR 1.88; CI 1.69-2.10). Resident admission characteristics associated with a greater risk of non-PPEDs solely are experiencing a change in mood (HR 1.09; CI 1.01-1.18) and delirium (HR 1.08; CI 1.04-1.13).

CONCLUSIONS AND IMPLICATIONS

PPEDs were associated with a similar cluster of NH resident characteristics as those transferred for non-ambulatory reasons, suggesting that the clinical distinction between PPEDs vs non-PPEDs within the NH might be unclear. These findings highlight that the PPED indicator could be revised to improve specificity.

Inclusion of patient-level emergency department characteristics to classify potentially redirectable visits to subacute care: a modified Delphi consensus study

BACKGROUND

Most patients transported by Ontario paramedics to the emergency department have non-emergent conditions and may be more appropriately served by subacute community-based care centres. We sought to determine consensus on a set of patient characteristics that could be useful to classify retrospective emergency department visits that had a high probability of being primary care-like and potentially redirectable to a subacute care centre by paramedics.

METHODS

We conducted a modified Delphi study to assess expert consensus on characteristics of patients transported by paramedics to the emergency department from August to October 2021. An expert Delphi committee was constructed of emergency and family physicians in Ontario using purposive sampling. Experts rated whether each characteristic was useful to be included in a classification to identify potentially redirectable visits retrospectively, as well as characteristic details (e.g., upper and lower bounds). Consensus was considered 75% agreement.

RESULTS

Sixteen experts participated in the study; the experts were mostly male (75%) and evenly divided between emergency and family medicine. After 2 rounds, consensus was achieved on 8 of 9 characteristics (89%). Four characteristics were determined as useful to classify potentially redirectable emergency department visits: age (81%), triage acuity (100%), specialist consult in the emergency department (94%) and emergency department visit outcome (81%). Specifications of each characteristic were refined as follows: young and middle-aged adults with a non-emergent triage acuity, did not receive a specialist physician consult in the emergency department and discharged from the emergency department.

INTERPRETATION

Strong consensus was achieved to specify a classification system for potentially redirectable emergency department visits. These results will be combined with knowledge of which subacute care centres could conduct the main physician interventions to retrospectively identify emergency department visits that could have been suitable for paramedic redirection for further research.

STUDY REGISTRATION

ID ISRCTN22901977.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

INTRODUCTION

Redirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed to retrospectively classify ED visits that may have been suitable for safe management in a subacute or virtual clinical setting. The EDAC has established face and content validity but has not been tested against a reference standard as a criterion.

OBJECTIVES

Our primary objective is to examine the agreement between the EDAC and ED physician judgements in retrospectively identifying ED visits suitable for subacute care management. Our secondary objective is to assess the validity of ED physicians' judgement as a criterion standard. Our tertiary objective is to examine how the ED physician's perception of a virtual ED care alternative correlates with the EDAC.

METHODS AND ANALYSIS

A randomised single-centre, single-blinded agreement study. We will randomly select ED charts between 1 January and 31 December 2019 from an academic hospital in Hamilton, Canada. ED charts will be randomly assigned to participating ED physicians who will evaluate if this ED visit could have been managed appropriately and safely in a subacute and/or virtual model of care. Each chart will be reviewed by two physicians independently. We compute our needed sample size to be 79 charts. We will use kappa statistics to measure inter-rater agreement. A repeated measures regression model of physician ratings will provide variance estimates that we will use to assess the intraclass correlation of ED physician ratings and the EDAC.

ETHICS AND DISSEMINATION

This study has been approved by the Hamilton Integrated Research Ethics Board (2022-14625). If validated, the EDAC may provide an ED-based classification to identify potentially avoidable ED visits, monitor ED visit trends, and proactively delineate those best suited for subacute or virtual care models.

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Hospitalizations for Ambulatory Care Sensitive Conditions in a Large City of Japan: a Descriptive Analysis Using Claims Data

BACKGROUND

Hospitalization for ambulatory care sensitive conditions (ACSCs) is an indicator of the quality of primary care in different health systems. In Japan, where patients can choose any healthcare facility with universal health coverage (UHC), data on these admissions are unknown.

OBJECTIVE

To describe the current situation of ACSC admissions in a city of Japan.

DESIGN

Retrospective observational study using claims data.

PARTICIPANTS

Beneficiaries aged 0-74 years of the National Health Insurance (NHI) program in a large city in the Greater Tokyo Area. We extracted ACSC admissions from all inpatient claims between April 2013 and March 2017.

MAIN MEASURES

We calculated age- and sex-specific annual ACSC admission rates for three categories: acute, chronic, and vaccine-preventable. We estimated the age-adjusted admission rates by ACSC category according to administrative districts and rate ratios using Poisson regression models. We also estimated medical expenditures and lengths of stay for ACSC admissions.

KEY RESULTS

Of 91,350 hospitalization episodes, we identified 7666 (8.4%) that were ACSC admissions. Males had higher annual ACSC admission rates than females (p < 0.001), especially for chronic ACSCs. Admission rates were lowest in those aged 15-39 years and higher in the youngest (0-4 years) and oldest (70-74 years) age groups. Age-adjusted chronic ACSC admission rates were lower in a newly developed area (rate ratio [RR]: 0.79, 95% confidence interval [CI]: 0.71-0.87) and higher in a residential area (RR: 1.14, 95% CI: 1.04-1.24) than in the center of the city. Total medical expenditures for all ACSC admissions accounted for 5.8% of the total inpatient expenditures of NHI in the city.

CONCLUSIONS

ACSC admission rates in Japan were higher for males than for females and showed a U-shaped trend in terms of age, as in other countries with UHC, and deferred by region. This study provided possible factors to reduce ACSC admissions.

Predicting Health Risks of Adult Asthmatics Susceptible to Indoor Air Quality Using Improved Logistic and Quantile Regression Models

The increasing global patterns for asthma disease and its associated fiscal burden to healthcare systems demand a change to healthcare processes and the way asthma risks are managed. Patient-centered health care systems equipped with advanced sensing technologies can empower patients to participate actively in their health risk control, which results in improving health outcomes. Despite having data analytics gradually emerging in health care, the path to well established and successful data driven health care services exhibit some limitations. Low accuracy of existing predictive models causes misclassification and needs improvement. In addition, lack of guidance and explanation of the reasons of a prediction leads to unsuccessful interventions. This paper proposes a modeling framework for an asthma risk management system in which the contributions are three fold: First, the framework uses a deep learning technique to improve the performance of logistic regression classification models. Second, it implements a variable sliding window method considering spatio-temporal properties of the data, which improves the quality of quantile regression models. Lastly, it provides a guidance on how to use the outcomes of the two predictive models in practice. To promote the application of predictive modeling, we present a use case that illustrates the life cycle of the proposed framework. The performance of our proposed framework was extensively evaluated using real datasets in which results showed improvement in the model classification accuracy, approximately 11.5–18.4% in the improved logistic regression classification model and confirmed low relative errors ranging from 0.018 to 0.160 in quantile regression model.

Proactive Health Support: a randomised controlled trial of telephone-based self-management support for persons at risk of hospital admission

BACKGROUND

Persons with frequent hospital admissions have a disease burden that may exceed their self-management skills. The evidence base of telephone-based interventions to support self-management is poor with mixed results. The aim of this study is to evaluate the effect of Proactive Health Support (PaHS): telephone-based self-management support for persons with risk of hospitalizations.

METHODS

This study is a national randomised controlled trial of PaHS versus usual universal tax-funded healthcare. Participants were persons at risk of emergency hospital admissions. The intervention began with a physical start-up session followed by telephone sessions of self-management support. The two co-primary outcomes were Health-Related Quality of Life (HRQoL) (Mental Health Component Summary Score of SF36v2) analysed with mixed models and hospital admissions analysed with Poisson regression at 6 months. Secondary outcomes were at 3- and 12-month follow-up and disease subgroup analyses.

RESULTS

During the study period, 6,402 persons were randomised (3,190 intervention, 3,212 control). HRQoL was significantly improved at 6 months (Est. 1.4992, P = <0.0001) and at 3 and 12 months on all 10 scales. There was no overall effect on hospital admissions at 6 months with an adjusted estimate of 0.0074 (P = 0.8691). Persons with diabetes had significant improvement of HRQoL and reduced hospital admissions.

CONCLUSIONS

The PaHS intervention improved HRQoL for all participants and reduced hospital admissions for persons with diabetes only.

The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Portuguese Primary Healthcare and Prevention Quality Indicators for Diabetes Mellitus - A Data Envelopment Analysis

BACKGROUND

Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings).

METHODS

We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care.

RESULTS

A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation.

CONCLUSION

Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.

Interventions to Prevent Potentially Avoidable Hospitalizations: A Mixed Methods Systematic Review

Background

The demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services.

Methods and Results

A mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations.

Conclusions

The syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.

Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018

Objective

This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China.

Methods

In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations.

Results

From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased.

Conclusions

Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08275-w.