Ambulatory care sensitive hospitalization rates in the aged Medicare population in Utah, 1990 to 1994: a rural-urban comparison

Admissions for ambulatory care sensitive conditions on rural islands and their association with patient experience: a multicentred prospective cohort study

OBJECTIVES

The rate of admissions for ambulatory care sensitive conditions (ACSCs) is a key outcome indicator for primary care, and patient experience (PX) is a crucial process indicator. Studies have reported higher rates of admission for ACSCs in rural areas than in urban areas. Whether there is an association between admissions for ACSCs and PX in rural areas has not been examined. This study aimed to document admissions for ACSCs on Japanese rural islands, and assess whether there was an association between the rate of admissions for ACSCs and PX.

DESIGN

Multicentred, prospective, cohort study SETTING: This study was conducted on five rural islands in Okinawa, Japan.

PARTICIPANTS

The study participants were all island inhabitants aged 65 years or older.

PRIMARY OUTCOME MEASURES

This study examined the association between ACSCs and PX assessed by a questionnaire, the Japanese Version of Primary Care Assessment Tool. ACSCs were classified using the International Classification of Diseases, Tenth Revision, and the rate of admissions for ACSCs in 1 year.

RESULTS

Of 1258 residents, 740 completed the questionnaire. This study documented 38 admissions for ACSCs (29 patients, males/females: 15/14, median age 81.9) that included congestive heart failure (11), pneumonia (7) and influenza (5). After adjusting for covariates and geographical clustering, admissions for ACSCs had a significant positive association with each patient's PX scores (OR per 1 SD increase=1.62, 95% CI 1.02-2.61).

CONCLUSIONS

Physicians serving rural areas need to stress the importance of preventive interventions for heart failure, pneumonia and influenza to reduce the number of admissions for ACSCs. Contrary to previous studies, our findings might be explained by close patient-doctor relationships on the rural islands.

The impact of marital status on health care utilization among Medicare beneficiaries

To explain prior literature showing that married Medicare beneficiaries achieve better health outcomes at half the per person cost of single beneficiaries, we examined different patterns of healthcare utilization as a potential driver.Using the Medicare Current Beneficiary Survey (MCBS) data, we sought to understand utilization patterns in married versus currently-not-married Medicare beneficiaries. We analyzed the relationship between marital status and healthcare utilization (classified based on setting of care utilization into outpatient, inpatient, and skilled nursing facility (SNF) use) using logistic regression modeling. We specified models to control for possible confounders based on the Andersen model of healthcare utilization.Based on 13,942 respondents in the MCBS dataset, 12,929 had complete data, thus forming the analytic sample, of whom 6473 (50.3%) were married. Of these, 58% (vs. 36% of those currently-not-married) were male, 45% (vs. 47%) were age >75, 24% (vs. 70%) had a household income below $25,000, 18% (vs. 14%) had excellent self-reported general health, and 56% (vs. 36%) had private insurance. Compared to unmarried respondents, married respondents had a trend toward higher odds of having a recent outpatient visit (unadjusted odds ratio (OR) 1.11, 95% confidence interval (CI) 1.04-1.19, adjusted odds ratio (AOR) 1.10, (CI) 0.99-1.22), and lower odds in the year prior to have had an inpatient stay (AOR 0.84, CI 0.72-0.99) or a SNF stay (AOR 0.55, CI 0.40-0.75).Based on MCBS data, odds of self-reported inpatient and SNF use were lower among married respondents, while unadjusted odds of outpatient use were higher, compared to currently-not-married beneficiaries.

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability

INTRODUCTION

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions.

METHOD

To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied.

RESULTS

There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings.

CONCLUSION

Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services.

The Relationship Between Rural Health Clinic Use and Potentially Preventable Hospitalizations and Emergency Department Visits Among Medicare Beneficiaries

PURPOSE

High rates of potentially preventable hospitalizations and emergency department (ED) visits indicate limited primary care access. Rural Health Clinics (RHCs) are intended to increase access to primary care. The goal of this study was to evaluate the role of RHCs and their impact on potentially preventable hospitalizations and ED visits among Medicare beneficiaries based on actual individual-level utilization patterns.

METHODS

With Medicare Part A and Part B claims data from 2007 to 2010, we constructed a series of individual-level negative binomial regression models to examine the relationship between RHC use and the number of potentially preventable hospitalizations and ED visits.

FINDINGS

RHC use was associated with a 27% increase in potentially preventable hospitalizations and a 24% increase in potentially preventable ED visits among older Medicare enrollees. Among younger, disabled Medicare beneficiaries, RHC use was associated with a 14% increase in potentially preventable hospitalizations and an 18% increase in potentially preventable ED visits. Potentially preventable hospitalizations and ED visits were more common among beneficiaries who were black or who had more chronic conditions.

CONCLUSIONS

The results of our study highlight that the Medicare population using RHCs is at especially high risk for potentially preventable hospitalizations and ED visits. The mechanisms behind this are not well understood and should receive continued attention from policy makers and researchers.

Socioeconomic Factors and Severity of Coronary Artery Disease in Patients Undergoing Coronary Angiography: A Multicentre Study of Arabian Gulf States

INTRODUCTION

Coronary artery disease (CAD) is a leading cause of death worldwide. The association of socioeconomic status with CAD is supported by numerous epidemiological studies. Whether such factors also impact the number of diseased coronary vessels and its severity is not well established.

MATERIALS AND METHODS

We conducted a prospective multicentre, multi-ethnic, cross sectional observational study of consecutive patients undergoing coronary angiography (CAG) at 5 hospitals in the Kingdom of Saudi Arabia and the United Arab Emirates. Baseline demographics, socioeconomic, and clinical variables were collected for all patients. Significant CAD was defined as ≥70% luminal stenosis in a major epicardial vessel. Left main disease (LMD) was defined as ≥50% stenosis in the left main coronary artery. Multi-vessel disease (MVD) was defined as having >1 significant CAD.

RESULTS

Of 1,068 patients (age 59 ± 13, female 28%, diabetes 56%, hypertension 60%, history of CAD 43%), 792 (74%) were from urban and remainder (26%) from rural communities. Patients from rural centres were older (61 ± 12 vs 58 ± 13), and more likely to have a history of diabetes (63 vs 54%), hypertension (74 vs 55%), dyslipidaemia (78 vs 59%), CAD (50 vs 41%) and percutaneous coronary intervention (PCI) (27 vs 21%). The two groups differed significantly in terms of income level, employment status and indication for angiography. After adjusting for baseline differences, patients living in a rural area were more likely to have significant CAD (adjusted OR 2.40 [1.47, 3.97]), MVD (adjusted OR 1.76 [1.18, 2.63]) and LMD (adjusted OR 1.71 [1.04, 2.82]). Higher income was also associated with a higher risk for significant CAD (adjusted OR 6.97 [2.30, 21.09]) and MVD (adjusted OR 2.49 [1.11, 5.56]), while unemployment was associated with a higher risk of significant CAD (adjusted OR 2.21, [1.27, 3.85]).

CONCLUSION

Communal and socioeconomic factors are associated with higher odds of significant CAD and MVD in the group of patients referred for CAG. The underpinnings of these associations (e.g. pathophysiologic factors, access to care, and system-wide determinants of quality) require further study.

Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions

Hospitalization for Ambulatory Care Sensitive Conditions (ACSH) is an accepted indicator of access to health care and avoidable morbidity. Accessible care of reasonable quality should reduce ACSH. Little research has examined the indicator’s external validity. We calculated standardized ACSH rates for 32 areas of Victoria, Australia (population 4.4 million). A representative survey measured access, disease prevalence, propensity to seek care, disease burden, social determinants of health services use, and behavioral risk factors. Regression analyses compared self-rated access with ACSH rates. Independent of prevalence, propensity to seek care, disease burden, and physician supply, better access was associated with lower ACSH rates. Results provide support for the ACSH indicator. When rural residence was considered, the covariate measuring access was not significant. However, rural residence also may contribute importantly to access. Results suggest both the complexity of the meaning of access and the desirability of further research to validate the ACSH indicator.

Hazards of Hospitalization for Ambulatory Care Sensitive Conditions among Older Women: Evidence of Greater Risks for African Americans and Hispanics

Hospitalization for Ambulatory Care Sensitive conditions (ACSH) has been widely accepted as an indicator of the accessibility and overall performance of primary health care. Previous studies have found conflicting evidence about ACSH disparities associated with race or ethnicity for older persons. This study estimates discrete-time ACSH hazards for women aged 69 or older, using longitudinal data with multivariate controls. Data are from the 1984 to 1990 Longitudinal Study of Aging, linked with Medicare claims. The multivariate results are adjusted for age, education, insurance and marital status, and other factors associated with health status and primary care access, and also for important indicators of need that include self-rated health, comorbidities, physical impairments, and previous hospitalizations. Many of these factors are permitted to vary across time for each individual, thus limiting measurement error. Results suggest that older African American and Hispanic women have markedly higher ACSH risks than older non-Hispanic white women.

Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

Objectives

To evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.

Design

Retrospective cohort study.

Setting

Department of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.

Participants

Medicare‐eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007–08 (baseline period) (N = 243,881).

Measurements

Two measures of longitudinal continuity were estimated using merged VA–Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.

Results

The incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02–1.07), intermediate (IRR = 1.04, 95% CI = 1.02–1.07), and low (IRR = 1.06, 95% CI = 1.03–1.09) UPC than in those with very high UPC (0.9–1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01–1.07), intermediate (OR = 1.03, 95% CI = 1.00–1.06), and low (OR = 1.04, 95% CI = 1.01–1.07) UPC were also more likely to be hospitalized during follow‐up. Results were similar for MMCI continuity scores.

Conclusion

Even slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

AHRQ prevention quality indicators to assess the quality of primary care of local providers: a pilot study from Italy

BACKGROUND

Outside the USA, Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs) have been used to compare the quality of primary care services only at a national or regional level. However, in several national health systems, primary care is not directly managed by the regions but is in charge of smaller territorial entities. We evaluated whether PQIs might be used to compare the performance of local providers such as Italian local health authorities (LHAs) and health districts.

METHODS

We analysed the hospital discharge abstracts of 44 LHAs (and 11 health districts) of five Italian regions (including ≈18 million residents) in 2008-10. Age-standardized PQI rates were computed following AHRQ specifications. Potential predictors were investigated using multilevel modelling.

RESULTS

We analysed 11 470 722 hospitalizations. The overall rates of preventable hospitalizations (composite PQI 90) were 1012, 889 and 988 (×100 000 inhabitants) in 2008, 2009 and 2010, respectively. Composite PQIs were able to differentiate LHAs and health districts and showed small variation in the performance ranking over years.

CONCLUSION

Although further research is required, our findings support the use of composite PQIs to evaluate the performance of relatively small primary health care providers (50 000-60 000 enrollees) in countries with universal health care coverage. Achieving high precision may be crucial for a structured quality assessment system to align hospitalization rate indicators with measures of other contexts of care (cost, clinical management, satisfaction/experience) that are typically computed at a local level.

Geographic and racial patterns of preventable hospitalizations for hypertension: Medicare beneficiaries, 2004-2009

OBJECTIVES

Hypertension as the primary reason for hospitalization is often used to indicate failure of the outpatient health-care system to prevent and control high blood pressure. Investigators have reported increased rates of these preventable hospitalizations for black people compared with white people; however, none have mapped them nationally by race.

METHODS

We used Medicare Part A data to estimate preventable hypertension hospitalizations from 2004-2009 using technical specifications published by the Agency for Healthcare Research and Quality. Rates per 100,000 beneficiaries were age- and sex-standardized to 2000 U.S. Census data. We mapped county-level rates by race and identified clusters of counties with extreme rates.

RESULTS

Black people had higher crude rates of these hospitalizations than white people for every year studied, and the test for an increasing linear time trend for the standardized rates was significant for both black and white people; that is, the gap between the races increased over time. For both races, clusters of high-rate counties occurred primarily in parts of Oklahoma, Texas, Southern Alabama, and Louisiana. High rates for white people were also found in parts of Appalachia. Large differences in rates among black and white people were found in a number of large urban areas and in parts of Florida and Alabama.

CONCLUSIONS

Racial disparities in preventable hospitalizations for hypertension persisted through 2009. The gap between black and white people is increasing, and these inequities exist unevenly across the country. Although this study was intended to be purely descriptive, future studies should use multivariate analyses to examine reasons for these unequal distributions.

Factors associated with hospitalisations for ambulatory care-sensitive conditions among persons with an intellectual disability: a publicly insured population perspective

BACKGROUND

Hospitalisations for ambulatory care-sensitive (ACS) conditions are used as an indicator of access to, and the quality of, primary care. The objective was to identify factors associated with hospitalisations for ACS conditions among adults with an intellectual disability (ID) in the context of a publicly insured healthcare system.

METHODS

This study examined adults with an ID living in a Canadian province between 1999 and 2003 identified from administrative databases. Using 5 years of data for the study population, characteristics of persons hospitalised or not hospitalised for ACS conditions were compared. Using a conceptual model, independent variables were selected and an analysis performed to identify which were associated with hospitalisations for ACS conditions. The correlated nature of the observations was accounted for statistically.

RESULTS

Living in a rural area [odds ratio (OR) 1.3; 95% confidence intervals (CI) = 1.0, 1.8], living in an area with a high proportion of First Nations people (OR 2.3; 95% CI = 1.3, 4.1), and experiencing higher levels of comorbidity (OR 25.2; 95% CI = 11.9, 53.0) were all associated with a higher likelihood of being hospitalised for an ACS condition. Residing in higher income areas had a protective effect (OR 0.56; 95% CI = 0.37, 0.85). None of the health service resource variables showed statistically significant associations.

CONCLUSIONS

Persons with an ID experience inequity in hospitalisations for ACS conditions according to rurality, income and proportion who are First Nations in a geographic area. This suggests that addressing the socio-economic problems of poorer areas and specifically areas densely populated by First Nations people may have an impact on the number of hospitalisations for ACS conditions. Study strengths and limitations and areas for potential future research are discussed.

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

The equality of resource allocation in health care under the National Health Insurance System in Taiwan

An ideal resource allocation in health care should ensure most people to access equal health care services while needed. Not only social welfare economists but also health policy makers concern with rational distribution of health care resources. Taiwan implemented a National Health Insurance (NHI) program in 1995, to reduce financial barriers for all residents with a universal health care system. Horizontal equity, an explicit goal of the NHI system, is to guarantee equal opportunity of access to health care. Accordingly, this study, utilizing cross-sectional data, proposes a multi-criteria decision-making approach with grey incidence analysis to measure horizontal equity of health care resource allocation of the NHI in Taiwan. From the findings of this empirical study, most resources are allocated in North Taiwan resulting in geographical disparity due to unbalanced health care resource allocation. And the large-scale hospitals are mostly congregated only at metropolitan regions; therefore, the access to health care services for patients in rural areas is still limited. Finally, the NHI in Taiwan is a single-payer for all hospitals, in which payment for health care suppliers can be adopted as an efficient strategy to induce the disparity of resource allocation and to redistribute national health care resource.

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

Background

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

Methods

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

Results

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

Conclusion

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

Uninsured hospitalizations: rural and urban differences

CONTEXT

Few studies have examined hospitalization patterns among the uninsured, especially from the perspective of rural and urban differences.

PURPOSE

To examine whether the patterns of uninsured hospitalizations differ in rural and urban hospitals and to identify the most prevalent and costly diagnoses among uninsured hospitalizations.

METHODS

We conducted a cross-sectional analysis of the Healthcare Cost and Utilization Project's National Inpatient Sample representing a total of 37,804,021 hospital discharges, with 4.9% of them generated by uninsured persons in 2002. We compared demographic and clinical characteristics and the proportion of frequent and costly diagnoses by rural and urban hospitals. We used multiple logistic regression models to examine the relationship between preventable conditions and rural and urban hospitals among uninsured hospitalizations.

FINDINGS

Uninsured persons discharged from rural hospitals were more likely than their urban counterparts to be working-age adults (82% vs 79%) and to reside in a ZIP code area with a median household income of less than $35,000 per year (56% vs 26%). Rural uninsured hospitalizations were more likely to be for preventable conditions than were urban uninsured hospitalizations (P < .001). The proportion of total hospital charges related to preventable hospitalizations was 15.5% in rural hospitals versus 10.0% in urban hospitals.

CONCLUSIONS

The patterns of uninsured hospitalizations in rural and urban hospitals were different in many ways. Providing adequate access to primary care could result in potential savings related to preventable hospitalizations for the uninsured, especially for rural hospitals.

Trends in rural and urban differentials in incidence rates for ruptured appendicitis under the National Health Insurance in Taiwan

OBJECTIVES

Rural-urban disparities in health remain a major focus of concern. This population-based study examined the performance of Taiwan's universal healthcare system in reducing rural-urban disparities in health, through better accessibility. Changes in the rates of ruptured appendicitis were compared between residents of remote and non-remote areas in Taiwan, under the National Health Insurance (NHI) programme.

METHODS

We identified all 128,930 patients undergoing appendectomy in Taiwan between 1996 and 2001. The NHI inpatient files, enrolment files, major disease files, hospital registry and the household registry were linked to provide comprehensive individual and hospital information. Probit regression analyses were used to obtain adjusted estimates.

RESULTS

During the first 3 years, although the differences between the remote and non-remote areas were apparent, they were seen to be narrowing. This downward trend continued, and, since 1999, few discernible differences have been observed. After adjusting for individual and hospital characteristics, over time, the ruptured appendix rate among remote area residents was seen to be decreasing significantly faster (1.1%) than among non-remote area residents. More specifically, the children showed a substantially steeper narrowing trend (3.3%) in rural-urban disparities, than did adults.

CONCLUSIONS

Our findings have shown a significant narrowing of health disparities between remote and non-remote populations, resulting from free access to care and more healthcare provision in remote areas under the NHI programme; particular success has been observed in rural children. Although certain disparities still exist, Taiwan's universal healthcare system has effectively reduced rural-urban disparities in access to care and in ultimate health outcomes.

The Role of Rural Health Clinics in Hospitalization due to Ambulatory Care Sensitive Conditions: A Study in Nebraska

CONTEXT

Hospitalization due to ambulatory care sensitive conditions (ACSCs) is often used as an indicator for measuring access to primary care. Rural health clinics (RHCs) provide basic primary care services for rural residents in health professional shortage areas (HPSAs). The relationship between RHCs and ACSCs is unclear.

PURPOSE

The purpose of this study was to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an acute or chronic ACSC as the reason for hospitalization.

METHODS

Nebraska hospital discharge data (1999-2001) and the 2003 Area Resource File were used in this analysis. A multilevel logistic regression analysis was used to examine the relationship between the presence of RHCs in rural HPSAs and the likelihood of having an ACSC as the reason for hospitalization, after controlling for individual characteristics and county-level contextual factors stratified by 3 age groups. The eligibility for logistic regression was limited to patients from 28 rural Nebraska counties designated as HPSAs in 2001. Patients with commercial payers were excluded from the study.

FINDINGS

Elderly patients residing in rural Nebraska HPSAs with at least one RHC were significantly less likely to have a hospitalization due to chronic ACSCs.

CONCLUSIONS

The presence of RHC is a significant factor associated with fewer hospitalizations for chronic ACSCs among the rural elderly residing in HPSAs.

Severity of illness and ambulatory care-sensitive conditions

This study describes how severity of illness may refine the definition of ambulatory care-sensitive conditions, or ACSCs. Hospital discharge abstract data from Philadelphia were combined with census data to develop population-based adjusted rates of hospitalization for diabetes and asthma, two ACSCs. By stratifying ACSC hospitalization by severity of illness, variations were observed by age, race, and gender. Minority groups may be at higher risk for less access to outpatient primary care and were observed to have higher rates of more severely ill, Stage 3 hospitalization. Geographic map displays indicated wide ranges of age-sex-adjusted rates for high-severity hospitalization in the five-county Philadelphia region. This refined ACSC measure may help to identify specific groups and clinical conditions within a population to assist health care planners estimate health care resources such as facilities, manpower, and programs, as well as to evaluate their outcomes.

Physician supply, physician diversity, and outcomes of primary health care for older persons in the United States

This study examines effects of physician supply and diversity on hospitalization for ambulatory care sensitive conditions (ACSH). Data are from 31 metropolitan areas in the 1984-1990 United States Longitudinal Study of Aging, and the Area Resource File. Discrete-time hazard models estimate ACSH risk. High ACSH risk may indicate problems with the accessibility or quality of primary care. Results show low supply areas have high risk. Adequate supply areas have significantly lower risk. Areas with greater supply have high risk, which may indicate supplier-induced hospitalization. Greater physician diversity reduces ACSH risk. Results support policies promoting physician placement in underserved areas, and those that educate minority physicians.

Congestive cardiac failure: urban and rural perspectives in Victoria

OBJECTIVE

Effective and timely care for congestive cardiac failure (CCF) should reduce the risks of hospitalisation. The purpose of this study is to describe variations in rates of hospital admissions for CCF in Victoria as an indicator of the adequacy of primary care services. Detailed analyses identify trends in hospitalisations, urban/rural differentials and variations by the Primary Care Partnerships (PCP).

SETTING

Acute care hospitals in Victoria.

DESIGN

Routine analyses of age and sex standardised admission rates of CCF in Victoria using the Victorian Admitted Episodes Dataset from 1993-1994 to 2000-2001.

SUBJECTS

All patients admitted to acute care hospitals in Victoria with the principal diagnosis of CCF between 1993-1994 and 2000-2001.

RESULTS

There were 8359 admissions for CCF in Victoria with an average of 7.37 bed days in 2000-2001. There was a significantly higher admission rate for CCF in rural areas compared to metropolitan in 2000/200--(2.53/1000 (2.44-2.62) and 1.80/1000 (1.75-1.85))--respectively. Small area analyses identified 17 PCP (14 of which were rural) with significantly higher admission rate ratios of CCF compared to Victoria.

CONCLUSION

Small area analyses of CCF have identified significant gaps in the management of CCF in the community. This may be a reflection of deficit in primary care availability, accessibility, or appropriateness. Detailed studies may be needed to determine the relative importance of these factors in Victoria for targeting specific interventions at the PCP level.

Características de la hospitalización evitable en España

BACKGROUND AND OBJECTIVE

Hospitalizations that could have been prevented with a timely and effective ambulatory care are known as avoidable hospitalizations (AH). The measure of AH is an indicator of the quality of primary health care centers. The objective of this study was to determine the factors that influence the level of AH at the Spanish public hospitals.

MATERIAL AND METHOD

We identified the characteristics of hospitalised patient as AH. We studied the total hospitalizations in public hospitals of Spain in 2000 related to AH.

RESULTS

AH admissions were the 15.8% of total in Spanish hospitals and the 16.6% of hospital stays. Patients' mean age was high, 54 years, males (age-adjusted OR = 1.54) with a large length of stay and presurgery stay, higher comorbidity (0.63 [0.8]), public financing, and admission was basically emergency-caused and in high complexity hospitals. There is a direct relationship between frequency of AH and hospital complexity.

CONCLUSIONS

The control of AH is very important because its repercussion on the total hospitalary case-mix. We observe an inducing effect of the hospital offer because the hospital capacity increase the number of AH admissions.

Potentially preventable care: ambulatory care-sensitive pediatric hospitalizations in South Carolina in 1998

OBJECTIVE

We examined pediatric hospitalizations to assess personal and community factors affecting potentially preventable ambulatory care-sensitive condition (ACSC) hospitalizations.

METHODS

Data came from the South Carolina 1998 Hospital Inpatient Encounter Database, which yielded 10,156 ACSC discharges among 81,808 pediatric hospitalizations. Analyses were performed at three levels: ACSC as a percentage of all hospitalizations, ACSC patients compared with other patients, and county ACSC rates.

RESULTS

Younger, male, and nonwhite children; children with Medicaid insurance coverage; and children living in rural areas, health professional shortage area-designated counties, and poorer counties with fewer heath care resources were more likely to be hospitalized with ACSCs. A high percentage of children living in poverty and an absence of federally qualified community health centers were predictive of high county ACSC rates.

CONCLUSION

Poverty and the absence of a provider serving low-income children increase ACSC rates. Monitoring changes in ACSC rates can be a tool for studying the effects of policy change.

Rural-urban differences in usual source of care and ambulatory service use: analyses of national data using Urban Influence Codes

BACKGROUND

Rural-urban disparities in access to and utilization of medical care have been a long-standing focus of concern.

OBJECTIVE

Using the nine-category Urban Influence Codes, this study examines the relationship between place of residence and having access and utilization of ambulatory health services.

RESEARCH DESIGN

Data come from the Medical Expenditure Panel Survey, conducted in 1996. Linear and logistic regression analyses assess the relationship between county type and having a usual source of care and ambulatory visits, controlling for demographic and health status measures.

RESULTS

Residents of counties that were totally rural were more likely to report having a usual source of care (adjusted OR: 1.98; CI: 1.01, 3.89) than residents of large metropolitan counties. Residents of places without a city of 10,000 or more, but adjacent to a metropolitan area, were also more likely to report having a usual source of care (adjusted OR: 1.92; CI: 1.16, 3.22). In a regression analysis, residents of the most rural places reported fewer visits during the year (B = -2.42, CI: -3.68, -1.32).

CONCLUSIONS

Results suggest that using rural and urban definitions that go beyond the traditional dichotomy of metropolitan and non-metropolitan may assist policymakers and researchers in identifying types of places where there is a disparity in access and subsequent utilization of health care. Rural residents, defined as totally rural in the urban influence coding scheme, may report having a health care provider but report fewer visits to health care providers during a year.

Potentially avoidable rehospitalizations following acute myocardial infarction by insurance status

Few studies have explored the impact of health insurance on patients with severe, chronic diseases. This retrospective study examined the association between health insurance and the risk of potentially avoidable rehospitalization in the 3 years following validated acute myocardial infarction (AMI) for a community-based probability sample of 683 patients admitted to 30 California hospitals in 1990-1991. In a multivariate analysis adjusted for measures of comorbidity burden, severity of illness, and AMI-related inpatient care, the risk of readmission was not significantly different among patients with no insurance, Medicare insurance, and non-Medicaid, non-Medicare ("private or other") insurance. However, compared to the latter group, patients with Medicaid were 2.6 times more likely to be readmitted for an AMI-related process (risk ratio. 2.61; 95% confidence interval, 1.33 to 5.11). Additional studies are needed to define the role of health insurance on clinical outcomes and health care access across a broader range of conditions and communities.

Are rural residents and Hispanics less satisfied with medical care? Evidence from the Permian Basin

Few population-based studies of consumers' perceptions of health care quality have included both rural residents and Hispanics. Using data collected through a random-digit telephone survey of households in the Permian Basin region of west Texas, an area with a relatively high percentage of Mexican Americans, we tested for rural/urban and ethnic differences in satisfaction with medical care. The study had several limitations, but the findings suggest that rural residents of this region rate the quality of their medical care overall more negatively than do their urban counterparts. No ethnic differences were found when controlling for demographic, social, economic, and health-status characteristics. Other factors, including part-time employment, a lack of continuous health insurance coverage, and poor health status appear to have a stronger, negative relationship with satisfaction. The collection and reporting of more specific measures of interpersonal and technical quality would further enable policy-makers, managers, and clinicians to better serve their patient populations.

Rural Medicare Beneficiaries’Use of Rural and Urban Hospitals

This report examines the use of rural and urban hospitals by rural Medicare beneficiaries. Many rural Medicare beneficiaries are treated in urban hospitals, primarily for specialized care that is not available locally. This study examines Medicare inpatient hospital discharge data for rural beneficiaries from fiscal year 1990 to fiscal year 1998. Utilization patterns by diagnosis-related group (DRG) are examined for fiscal year (FY) 1997. The percentage of rural beneficiaries treated in urban hospitals ranged from 30 percent to 36 percent during the study period. For the most frequently occurring DRGs among rural beneficiaries, which were those for routine conditions, treatment occurred predominantly in rural hospitals. The conditions most often responsible for rural beneficiaries' use of urban hospitals during this period reflected the need for coronary and other specialized surgical care. The stability of volume and case-mix throughout the study period underscores the viability of rural hospitals during a period of substantial change in the organization of health care provision.