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Zasada W, Cholerzyńska H, Kłosiewicz T, Rozmarynowska M, Konieczka P, Lasik J, Jankowski T, Kubiak S, Bielska IA. Why do patients who are triaged as low-acuity visit the emergency department? - A Polish perspective. Int Emerg Nurs 2024; 76:101506. [PMID: 39182473 DOI: 10.1016/j.ienj.2024.101506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 08/01/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Emergency departments (EDs) worldwide are dealing with overcrowding, system fragmentation, and coordination problems, which impact patient wait times, staff job satisfaction, and patient outcomes. Inappropriate ED visits, particularly those for low acuity conditions, exacerbate these challenges. However, the motivations behind these visits are poorly understood, with limited data from the patient perspective. This study investigated patient-reported motives behind ED visits triaged as low acuity in Poznan, Poland, to propose health care system flow enhancements. MATERIAL AND METHODS A cross-sectional survey and retrospective chart review were conducted in the ED of the Hipolit Cegielski Medical Center in Poznań, Poland, over three months in 2022-23. Patients who were triaged to have low acuity conditions were invited to participate in the survey. The data collected through the questionnaire included patient and ED visit characteristics. Additional information on the visits was extracted from the patient charts. MAIN RESULTS This study involved 293 patients who underwent low-acuity triage. Among them, 58 % were deemed to have conditions that could have been treated in primary care. Most of the patients (74 %) visited the ED of their own volition due to concerns about their health. Other reasons for ED attendance were challenges accessing primary care or a specialist clinic (11 %), system navigation problems (5 %), or a lack of trust in their primary care provider (2 %). CONCLUSIONS This study showed that of the patients surveyed, the majority had conditions that could have been treated outside of the ED setting. We recommend prioritizing education, particularly among younger adults, to increase awareness about nonurgent care options while improving health care policies.
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Affiliation(s)
- Wiktoria Zasada
- Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Hanna Cholerzyńska
- Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland.
| | - Tomasz Kłosiewicz
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Monika Rozmarynowska
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Patryk Konieczka
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Julian Lasik
- Chair of Emergency Medicine, Poznan University of Medical Sciences, 7 Rokietnicka Street, 60-608 Poznań, Poland
| | - Tomasz Jankowski
- University Clinical Hospital in Poznań, 49 Przybyszewskiego Street, 60-355 Poznań, Poland
| | - Sebastian Kubiak
- University Clinical Hospital in Poznań, 49 Przybyszewskiego Street, 60-355 Poznań, Poland
| | - Iwona A Bielska
- Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Thomas RL, Millett C, Sousa Soares RD, Hone T. More doctors, better health? A generalised synthetic control approach to estimating impacts of increasing doctors under Brazil's Mais Medicos programme. Soc Sci Med 2024; 358:117222. [PMID: 39181082 DOI: 10.1016/j.socscimed.2024.117222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/10/2024] [Accepted: 08/09/2024] [Indexed: 08/27/2024]
Abstract
Worldwide, there are an insufficient number of primary care physicians to provide accessible, high-quality primary care services. Better knowledge on the health impacts of policies aimed at improving access to primary care physicians is important for informing future policies. Using a generalised synthetic control estimator (GSC), we estimate the effect of the increase in primary care physicians from the Programa Mais Médicos in Brazil. The GSC allows us to estimates a continuous treatment effects which are heterogenous by region. We exploit the variation in physicians allocated to each Brazilian microregion to identify the impact of an increasing Mais Médicos primary care physicians. We explore hospitalisations and mortality rates (both total and from ambulatory care sensitive conditions) as outcomes. Our analysis differs from previous work by estimating the impact of the increase in physician numbers, as opposed to the overall impact of programme participation. We examine the impact on hospitalisations and mortality rates and employ a panel dataset with monthly observations of all Brazilian microregion over the period 2008-2017. We find limited effects of an increase in primary care physicians impacting health outcomes - with no significant impact of the Programa Mais Médicos on hospitalisations or mortality rates. Potential explanations include substitution of other health professionals, impacts materialising over the longer-term, and poor within-region allocation of Mais Médicos physicians.
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Affiliation(s)
- Rhys Llewellyn Thomas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Christopher Millett
- Public Health Policy Evaluation Unit, Imperial College London, London, UK; NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | | | - Thomas Hone
- Public Health Policy Evaluation Unit, Imperial College London, London, UK
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Ohta R, Yoshioka K, Sano C. Evolution of the roles of family physicians through collaboration with rehabilitation therapists in rural community hospitals: a grounded theory approach. BMC PRIMARY CARE 2024; 25:283. [PMID: 39097702 PMCID: PMC11298079 DOI: 10.1186/s12875-024-02540-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 07/24/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND The role of rural family physicians continues to evolve to accommodate the comprehensive care needs of aging societies. For older individuals in rural areas, rehabilitation is vital to ensure that they can continue to perform activities of daily living. In this population, a smooth discharge following periods of hospitalization is essential and requires management of multimorbidity, and rehabilitation therapists may require support from family physicians to achieve optimal outcomes. Therefore, this study aimed to investigate changes in the roles of rural family physicians in patient rehabilitation. METHODS An ethnographic analysis was conducted with rural family physicians and rehabilitation therapists at a rural Japanese hospital. A constructivist grounded theory approach was applied as a qualitative research method. Data were collected from the participants via field notes and semi-structured interviews. RESULTS Using a grounded theory approach, the following three themes were developed regarding the establishment of effective interprofessional collaboration between family physicians and therapists in the rehabilitation of older patients in rural communities: 1) establishment of mutual understanding and the perception of psychological safety; 2) improvement of relationships between healthcare professionals and their patients; and 3) creation of new roles in rural family medicine to meet evolving needs. CONCLUSION Ensuring continual dialogue between family medicine and rehabilitation departments helped to establish understanding, enhance knowledge, and heighten mutual respect among healthcare workers, making the work more enjoyable. Continuous collaboration between departments also improved relationships between professionals and their patients, establishing trust in collaborative treatment paradigms and supporting patient-centered approaches to family medicine. Within this framework, understanding the capabilities of family physicians can lead to the establishment of new roles for them in rural hospitals. Family medicine plays a vital role in geriatric care in community hospitals, especially in rural primary care settings. The role of family medicine in hospitals should be investigated in other settings to improve geriatric care and promote mutual learning and improvement among healthcare professionals.
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Affiliation(s)
- Ryuichi Ohta
- Community Care, Unnan City Hospital, 96-1 Iida, Daito-Cho, Unnan, Shimane Prefecture, 699-1221, Japan.
| | - Kentaro Yoshioka
- Community Care, Unnan City Hospital, 96-1 Iida, Daito-Cho, Unnan, Shimane Prefecture, 699-1221, Japan
| | - Chiaki Sano
- Department of Community Medicine Management, Faculty of Medicine, Shimane University, 89-1 Enya Cho, Izumo , Shimane Prefecture, 693-8501, Japan
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Kaskie B, Shehu E, Ohms K, Liebzeit D, Ashida S, Buck HG. Critical Elements of Care Coordination for Older Persons in Rural Communities: An Evaluation of the Iowa Return to Community Service Demonstration. J Appl Gerontol 2024; 43:678-687. [PMID: 38087499 DOI: 10.1177/07334648231218091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
We evaluated the Iowa Return to Community, a service demonstration designed to coordinate care and reduce preventable healthcare utilization among at-risk older persons living at home in rural communities. During 2021, 262 older persons elected to participate in the IRTC program. Individuals who participated were more likely to live in micropolitan areas (OR = 2.30, 95% CI 1.34-3.95) relative to metropolitan locations. Individuals who used recommended services were more likely to be men (OR 3.65, 95% CI 1.16-11.51) and more likely to live in rural (OR 17.48, 95% CI 1.37-223.68) and micropolitan areas (OR 3.17, 95% CI 1.00-10.05). However, prevention of health care use corresponded more with consistent and prolonged IRTC program engagement rather than volume of service use. The IRTC constitutes a population aging and rural health strategy to reduce unnecessary health care use while supporting individual preferences to remain at home.
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Affiliation(s)
- Brian Kaskie
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Erblin Shehu
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
| | - Kent Ohms
- Iowa Department on Aging, Des Moines, IA, USA
| | | | - Sato Ashida
- College of Public Health, Department of Health Management and Policy, University of Iowa, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, IA, USA
| | - Harleah G Buck
- College of Nursing, University of Iowa, Iowa City, IA, USA
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Cole MB, Strackman BW, Lasser KE, Lin MY, Paasche-Orlow MK, Hanchate AD. Medicaid Expansion and Preventable Emergency Department Use by Race/Ethnicity. Am J Prev Med 2024; 66:989-998. [PMID: 38342480 PMCID: PMC11102850 DOI: 10.1016/j.amepre.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
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.
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Affiliation(s)
- Megan B Cole
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Braden W Strackman
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Karen E Lasser
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Meng-Yun Lin
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Amresh D Hanchate
- Division of Public Health Sciences, Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, North Carolina; Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts.
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Ronksley PE, Scory TD, McRae AD, MacRae JM, Manns BJ, Lang E, Donald M, Hemmelgarn BR, Elliott MJ. Emergency Department Use Among Adults Receiving Dialysis. JAMA Netw Open 2024; 7:e2413754. [PMID: 38809552 PMCID: PMC11137633 DOI: 10.1001/jamanetworkopen.2024.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/27/2024] [Indexed: 05/30/2024] Open
Abstract
Importance People with kidney failure receiving maintenance dialysis visit the emergency department (ED) 3 times per year on average, which is 3- to 8-fold more often than the general population. Little is known about the factors that contribute to potentially preventable ED use in this population. Objective To identify the clinical and sociodemographic factors associated with potentially preventable ED use among patients receiving maintenance dialysis. Design, Setting, and Participants This cohort study used linked administrative health data within the Alberta Kidney Disease Network to identify adults aged 18 years or older receiving maintenance dialysis (ie, hemodialysis or peritoneal dialysis) between April 1, 2010, and March 31, 2019. Patients who had been receiving dialysis for more than 90 days were followed up from cohort entry (defined as dialysis start date plus 90 days) until death, outmigration from the province, receipt of a kidney transplant, or end of study follow-up. The Andersen behavioral model of health services was used as a conceptual framework to identify variables related to health care need, predisposing factors, and enabling factors. Data were analyzed in March 2024. Main Outcomes and Measures Rates of all-cause ED encounters and potentially preventable ED use associated with 4 kidney disease-specific ambulatory care-sensitive conditions (hyperkalemia, heart failure, volume overload, and malignant hypertension) were calculated. Multivariable negative binomial regression models were used to examine the association between clinical and sociodemographic factors and rates of potentially preventable ED use. Results The cohort included 4925 adults (mean [SD] age, 60.8 [15.5] years; 3071 males [62.4%]) with kidney failure receiving maintenance hemodialysis (3183 patients) or peritoneal dialysis (1742 patients) who were followed up for a mean (SD) of 2.5 (2.0) years. In all, 3877 patients had 34 029 all-cause ED encounters (3100 [95% CI, 2996-3206] encounters per 1000 person-years). Of these, 755 patients (19.5%) had 1351 potentially preventable ED encounters (114 [95% CI, 105-124] encounters per 1000 person-years). Compared with patients with a nonpreventable ED encounter, patients with a potentially preventable ED encounter were more likely to be in the lowest income quintile (38.8% vs 30.9%; P < .001); to experience heart failure (46.8% vs 39.9%; P = .001), depression (36.6% vs 32.5%; P = .03), and chronic pain (60.1% vs 54.9%; P = .01); and to have a longer duration of dialysis (3.6 vs 2.6 years; P < .001). In multivariable regression analyses, potentially preventable ED use was higher for younger adults (incidence rate ratio [IRR], 1.69 [95% CI, 1.33-2.15] for those aged 18 to 44 years) and patients with chronic pain (IRR, 1.35 [95% CI, 1.14-1.61]), greater material deprivation (IRR, 1.57 [95% CI, 1.16-2.12]), a history of hyperkalemia (IRR, 1.31 [95% CI, 1.09-1.58]), and historically high ED use (ie, ≥3 ED encounters in the prior year; IRR, 1.46 [95% CI, 1.23-1.73). Conclusions and Relevance In this study of adults receiving maintenance dialysis in Alberta, Canada, among those with ED use, 1 in 5 had a potentially preventable ED encounter; reasons for such encounters were associated with both psychosocial and medical factors. The findings underscore the need for strategies that address social determinants of health to avert potentially preventable ED use in this population.
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Affiliation(s)
- Paul E. Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Tayler D. Scory
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Andrew D. McRae
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer M. MacRae
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden J. Manns
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maoliosa Donald
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R. Hemmelgarn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Meghan J. Elliott
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Mahmoudi E, Lin P, Rubenstein D, Guetterman T, Leggett A, Possin KL, Kamdar N. Use of preventive service and potentially preventable hospitalization among American adults with disability: Longitudinal analysis of Traditional Medicare and commercial insurance. Prev Med Rep 2024; 40:102663. [PMID: 38464419 PMCID: PMC10920729 DOI: 10.1016/j.pmedr.2024.102663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024] Open
Abstract
Objective Examine the association between traditional Medicare (TM) vs. commercial insurance and the use of preventive care and potentially preventable hospitalization (PPH) among adults (18+) with disability [cerebral palsy/spina bifida (CP/SB); multiple sclerosis (MS); traumatic spinal cord injury (TSCI)] in the United States. Methods Using 2008-2016 Medicare and commercial claims data, we compared adults with the same disability enrolled in TM vs. commercial insurance [Medicare: n = 21,599 (CP/SB); n = 7,605 (MS); n = 4,802 (TSCI); commercial: n = 11,306 (CP/SB); n = 6,254 (MS); n = 5,265 (TSCI)]. We applied generalized estimating equations to address repeated measures, comparing cases with controls. All models were adjusted for age, sex, race/ethnicity, and comorbid conditions. Results Compared with commercial insurance, enrolling in TM reduced the odds of using preventive services. For example, adjusted odds ratios (OR) of annual wellness visits in TM vs. commercial insurance were 0.31 (95% confidence interval (CI): 0.28-0.34), 0.32 (95% CI: 0.28-0.37), and 0.19 (95% CI: 0.17-0.22) among adults with CP/SB, TSCI, and MS, respectively. Furthermore, PPH risks were higher in TM vs. commercial insurance. ORs of PPH in TM vs. commercial insurance were 1.50 (95% CI: 1.18-1.89), 1.83 (95% CI: 1.40-2.41), and 2.32 (95% CI: 1.66-3.22) among adults with CP/SB, TSCI, and MS, respectively. Moreover, dual-eligible adults had higher odds of PPH compared with non-dual-eligible adults [CP/SB: OR = 1.47 (95% CI: 1.25-1.72); TSCI: OR = 1.61 (95% CI: 1.35-1.92), and MS: OR = 1.80 (95% CI: 1.55-2.10)]. Conclusions TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.
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Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dana Rubenstein
- Clinical and Translational Science Institute, Duke University School of Medicine, 701 West Main Street, Durham, NC, USA
| | - Timothy Guetterman
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amanda Leggett
- Institute of Gerontology & Department of Psychology, Wayne State University, Detroit, MI, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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Wang J, Xu DR, Zhang Y, Fu H, Wang S, Ju K, Chen C, Yang L, Jian W, Chen L, Liao X, Xiao Y, Wu R, Jakovljevic M, Chen Y, Pan J. Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol. Glob Health Res Policy 2024; 9:11. [PMID: 38504369 PMCID: PMC10949688 DOI: 10.1186/s41256-024-00350-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
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.
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Affiliation(s)
- Jianjian Wang
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Dong Roman Xu
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Sijiu Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Ke Ju
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chu Chen
- School of Health Management, Fujian Medical University, Fujian, China
| | - Lian Yang
- School of Public Health, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyang Liao
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Xiao
- China National Health Development Research Center, Beijing, China
| | - Ruixian Wu
- Center for Health Statistics and Information, National Health Commission, Beijing, China
| | - Mihajlo Jakovljevic
- Institute of Advanced Manufacturing Technologies, Peter the Great St. Petersburg Polytechnic University, St. Petersburg, Russia
- Institute of Comparative Economic Studies, Faculty of Economics, Hosei University, Tokyo, Japan
- Department of Global Health Economics and Policy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Yaolong Chen
- Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences (2021RU017), School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.
- World Health Organization Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China.
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Gustafsson PE, Fonseca-Rodríguez O, Castel Feced S, San Sebastián M, Bastos JL, Mosquera PA. A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population. Soc Sci Med 2024; 343:116589. [PMID: 38237285 DOI: 10.1016/j.socscimed.2024.116589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/07/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.
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Affiliation(s)
- Per E Gustafsson
- Department of Epidemiology and Global Health, Umeå University, Sweden.
| | | | - Sara Castel Feced
- Department of Microbiology, Pediatrics, Radiology, and Public Health, University of Zaragoza, Spain
| | | | | | - Paola A Mosquera
- Department of Epidemiology and Global Health, Umeå University, Sweden
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Dröge P, Ruhnke T, Fischer-Rosinsky A, Henschke C, Keil T, Möckel M, Günster C, Slagman A. Patients pathways before and after treatments in emergency departments: A retrospective analysis of secondary data in Germany. Health Policy 2023; 138:104944. [PMID: 38016261 DOI: 10.1016/j.healthpol.2023.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 11/06/2023] [Accepted: 11/10/2023] [Indexed: 11/30/2023]
Abstract
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 %).
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Affiliation(s)
| | | | - Antje Fischer-Rosinsky
- Charité - Universitätsmedizin Berlin, Emergency and Acute Medicine (CVK, CCM), Berlin, Germany
| | - Cornelia Henschke
- Dept. Health Care Management, Berlin University of Technology, Berlin, Germany
| | - Thomas Keil
- Charité - Universitätsmedizin Berlin, Institute of Social Medicine, Epidemiology and Health Economics, Berlin, Germany; Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; State Institute of Health I, Bavarian Health and Food Safety Authority, Erlangen, Germany
| | - Martin Möckel
- Charité - Universitätsmedizin Berlin, Emergency and Acute Medicine (CVK, CCM), Berlin, Germany
| | | | - Anna Slagman
- Charité - Universitätsmedizin Berlin, Emergency and Acute Medicine (CVK, CCM), Berlin, Germany
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Benning L, Kleinekort J, Röttger MC, Köhne N, Wehrle J, Blum M, Busch HJ, Hans FP. Factors influencing the occurrence of ambulatory care sensitive conditions in the emergency department - a single-center cross-sectional study. Front Med (Lausanne) 2023; 10:1256447. [PMID: 38020113 PMCID: PMC10665907 DOI: 10.3389/fmed.2023.1256447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background and importance The differentiation between patients who require urgent care and those who could receive adequate care through ambulatory services remains a challenge in managing patient volumes in emergency departments (ED). Different approaches were pursued to characterize patients that could safely divert to ambulatory care. However, this characterization remains challenging as the urgency upon presentation is assessed based on immediately available characteristics of the patients rather than on subsequent diagnoses. This work employs a core set of Ambulatory Care Sensitive Conditions (core-ACSCs) in an ED to describe conditions that do not require inpatient care if treated adequately in the ambulatory care sector. It subsequently analyzes the corresponding triage levels and admission status to determine whether core-ACSCs relevantly contribute to patient volumes in an ED. Settings and participants Single center cross-sectional analysis of routine data of a tertiary ED in 2019. Outcome measures and analysis The proportion of core-ACSCs among all presentations was assessed. Triage levels were binarily classified as "urgent" and "non-urgent," and the distribution of core-ACSCs in both categories was studied. Additionally, the patients presenting with core-ACSCs requiring inpatient care were assessed based on adjusted residuals and logistic regression. The proportion being discharged home underwent further investigation. Main results This study analyzed 43,382 cases of which 10.79% (n = 4,683) fell under the definition of core-ACSC categories. 65.2% of all core-ACSCs were urgent and received inpatient care in 62.8% of the urgent cases. 34.8% of the core-ACSCs were categorized as non-urgent, 92.4% of wich were discharged home. Age, triage level and sex significantly affected the odds of requiring hospital admission after presenting with core-ACSCs. The two core-ACSCs that mainly contributed to non-urgent cases discharged home after the presentation were "back pain" and "soft tissue disorders." Discussion Core-ACSCs contribute relevantly to overall ED patient volume but cannot be considered the primary drivers of crowding. However, once patients presented to the ED with what was later confirmed as a core-ACSC, they required urgent care in 65.2%. This finding highlights the importance of effective ambulatory care to avoid emergency presentations. Additionally, the core-ACSC categories "back pain" and "soft tissue disorders" were often found to be non-urgent and discharged home. Although further research is required, these core-ACSCs could be considered potentially avoidable ED presentations. Clinical trial registration The study was registered in the German trials register (DRKS-ID: DRKS00029751) on 2022-07-22.
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Affiliation(s)
- Leo Benning
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Jan Kleinekort
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Michael Clemens Röttger
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Nora Köhne
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Julius Wehrle
- Data Integration Center, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Marco Blum
- Data Integration Center, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Hans-Jörg Busch
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Felix Patricius Hans
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
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12
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Mountain R, Kim D, Johnson KM. Budget impact analysis of adopting primary care-based case detection of chronic obstructive pulmonary disease in the Canadian general population. CMAJ Open 2023; 11:E1048-E1058. [PMID: 37935489 PMCID: PMC10635706 DOI: 10.9778/cmajo.20230023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND An estimated 70% of Canadians with chronic obstructive pulmonary disease (COPD) have not received a diagnosis, creating a barrier to early intervention, and there is growing interest in the value of primary care-based opportunistic case detection for COPD. We sought to build on a previous cost-effectiveness analysis by evaluating the budget impact of adopting COPD case detection in the Canadian general population. METHODS We used a validated discrete-event microsimulation model of COPD in the Canadian general population aged 40 years and older to assess the costs of implementing 8 primary care-based case detection strategies over 5 years (2022-2026) from the health care payer perspective. Strategies varied in eligibility criteria (based on age, symptoms or smoking history) and testing technology (COPD Diagnostic Questionnaire [CDQ] or screening spirometry). Costs were determined from Canadian studies and converted to 2021 Canadian dollars. Key parameters were varied in one-way sensitivity analysis. RESULTS All strategies resulted in higher total costs compared with routine diagnosis. The most cost-effective scenario (the CDQ for all patients) had an associated total budget expansion of $423 million, with administering case detection and subsequent diagnostic spirometry accounting for 86% of costs. This strategy increased the proportion of individuals diagnosed with COPD from 30.4% to 37.8%, and resulted in 4.6 million referrals to diagnostic spirometry. Results were most sensitive to uptake in primary care. INTERPRETATION Adopting a national COPD case detection program would be an effective method for increasing diagnosis of COPD, dependent on successful uptake. However, it will require prioritisation by budget holders and substantial additional investment to improve access to diagnostic spirometry.
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Affiliation(s)
- Rachael Mountain
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
| | - Dexter Kim
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
| | - Kate M Johnson
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences (Mountain, Johnson), University of British Columbia, Vancouver, BC; Centre for Health Informatics, Computing, and Statistics (Mountain), Lancaster Medical School, Lancaster University, Lancaster, UK; Faculty of Medicine (Kim) and Division of Respiratory Medicine, Department of Medicine (Johnson), University of British Columbia, Vancouver, BC
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13
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Nishioka D, Saito J, Ueno K, Kondo N. Sociodemographic inequities in unscheduled asthma care visits among public assistance recipients in Japan: additional risk by household composition among workers. BMC Health Serv Res 2023; 23:1084. [PMID: 37821936 PMCID: PMC10568886 DOI: 10.1186/s12913-023-10110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 10/03/2023] [Indexed: 10/13/2023] Open
Abstract
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.
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Affiliation(s)
- Daisuke Nishioka
- Department of Medical Statistics, Osaka Medical and Pharmaceutical University, Research & Development Center, 2-7 Daigaku-Machi, Takatsuki-Shi, Osaka, 569-8686, Japan.
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Yoshida-Konoe-Cho, Sakyo-Ku, Kyoto, Kyoto, Japan.
| | - Junko Saito
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, Japan
| | - Keiko Ueno
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Yoshida-Konoe-Cho, Sakyo-Ku, Kyoto, Kyoto, Japan
| | - Naoki Kondo
- Department of Social Epidemiology, Graduate School of Medicine and School of Public Health, Kyoto University, Yoshida-Konoe-Cho, Sakyo-Ku, Kyoto, Kyoto, Japan
- Institute for Future Initiatives, the University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, Japan
- Japan Agency for Gerontological Evaluation Study (JAGES Agency), 6-3-5 Yanaka, Taito-Ku, Tokyo, Japan
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14
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Loyd C, Blue K, Turner L, Weber A, Guy A, Zhang Y, Martin RC, Kennedy RE, Brown C. National Norms for Hospitalizations Due to Ambulatory Care Sensitive Conditions among Adults in the US. J Gen Intern Med 2023; 38:2953-2959. [PMID: 36941421 PMCID: PMC10027258 DOI: 10.1007/s11606-023-08161-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Christine Loyd
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Kylie Blue
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Laci Turner
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley Weber
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley Guy
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yue Zhang
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cynthia Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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15
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Satokangas M, Arffman M, Agerholm J, Thielen K, Hougaard CØ, Andersen I, Burström B, Keskimäki I. Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015. BMC Health Serv Res 2023; 23:835. [PMID: 37550672 PMCID: PMC10405465 DOI: 10.1186/s12913-023-09855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 07/27/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. METHODS We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. RESULTS Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment. CONCLUSIONS While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.
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Affiliation(s)
- Markku Satokangas
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland.
- Network of Academic Health Centres and Department of General Practice and Primary Health Care, University of Helsinki, P.O. Box 20, 00014, Helsinki, Finland.
| | - Martti Arffman
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Janne Agerholm
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Karsten Thielen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Ørsted Hougaard
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ingelise Andersen
- Section of Social Medicine, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ilmo Keskimäki
- Health Economics and Equity in Health Care, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
- Faculty of Social Sciences, Tampere University, 33014, Tampere, Finland
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16
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Zou K, Duan Z, Zhang Z, Hu J, Zhang J, Pan J, Liu C, Yang M. Examining clinical capability of township healthcare centres for rural health service planning in Sichuan, China: an administrative data analysis. BMJ Open 2023; 13:e067028. [PMID: 37105701 PMCID: PMC10151931 DOI: 10.1136/bmjopen-2022-067028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Kun Zou
- West China Research Centre of Rural Health Development, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
- Department of Pharmacy, Evidence-Based Pharmacy Center, NMPA Key Laboratory for Technical Research on Drug Products In Vitro and In Vivo Correlation, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University West China Second University Hospital, Chengdu, China
| | - Zhanqi Duan
- Sichuan Provincial Big Data Center, Chengdu, Sichuan, China
| | - Ziwu Zhang
- Sichuan Provincial Big Data Center, Chengdu, Sichuan, China
| | - Jinliang Hu
- Institute of Health Policy and Hospital Management Research, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
| | - Juying Zhang
- Department of Epidemiology and Biostatistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Chaojie Liu
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Min Yang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, China
- Faculty of Health, Art and Design, Swinbune Technology University, Melbourne, Victoria, Australia
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17
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Beckman AL, Frakt AB, Duggan C, Zheng J, Orav EJ, Tsai TC, Figueroa JF. Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2023; 4:e225530. [PMID: 36826828 PMCID: PMC9958527 DOI: 10.1001/jamahealthforum.2022.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Importance Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges. Objective To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare. Design, Setting, and Participants Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022. Main Outcomes and Measures Hospitalizations, observation stays, and ED direct discharges for ACSCs. Results The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12). Conclusions and Relevance The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.
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Affiliation(s)
- Adam L. Beckman
- Harvard Medical School, Boston, Massachusetts,Harvard Business School, Boston, Massachusetts
| | - Austin B. Frakt
- US Department of Veterans Affairs, Boston Healthcare System, Boston University School of Public Health, Boston, Massachusetts,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ciara Duggan
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Rosenthal MA, Ranji SR, Kanzaria HK, Ortiz GM, Chase J, Chodos AH, Nguyen OK, Rodriguez EG, Makam AN. Characterizing patients hospitalized without an acute care indication: A retrospective cohort study. J Hosp Med 2023; 18:294-301. [PMID: 36757173 DOI: 10.1002/jhm.13061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/04/2023] [Accepted: 01/25/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays. OBJECTIVE To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs. DESIGNS, SETTINGS, AND PARTICIPANTS A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital. MAIN OUTCOME AND MEASURES Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics. RESULTS Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001). CONCLUSIONS Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary.
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Affiliation(s)
- Molly A Rosenthal
- Department of General Internal Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Sumant R Ranji
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California, San Francisco, California, USA
- Department of Care Coordination, San Francisco Department of Public Health, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Gabriel M Ortiz
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Jack Chase
- Department of Family and Community Medicine, University of California, San Francisco, California, USA
| | - Anna H Chodos
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Oanh K Nguyen
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Eric G Rodriguez
- Department of Care Coordination, San Francisco Department of Public Health, San Francisco, California, USA
| | - Anil N Makam
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
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North F, Garrison GM, Jensen TB, Pecina J, Stroebel R. Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits. Health Serv Res Manag Epidemiol 2023; 10:23333928231214169. [PMID: 38023369 PMCID: PMC10664417 DOI: 10.1177/23333928231214169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/30/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. Methods We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. Results There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Conclusion Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.
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Affiliation(s)
- Frederick North
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | | | - Teresa B Jensen
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Stroebel
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
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20
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Duminy L, Ress V, Wild EM. Complex community health and social care interventions – Which features lead to reductions in hospitalizations for ambulatory care sensitive conditions? A systematic literature review. Health Policy 2022; 126:1206-1225. [DOI: 10.1016/j.healthpol.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
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21
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Launders N, Dotsikas K, Marston L, Price G, Osborn DPJ, Hayes JF. The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis. PLoS One 2022; 17:e0272498. [PMID: 35980891 PMCID: PMC9387848 DOI: 10.1371/journal.pone.0272498] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 07/20/2022] [Indexed: 11/18/2022] Open
Abstract
Background People with severe mental illness (SMI) are at higher risk of physical health conditions compared to the general population, however, the impact of specific underlying health conditions on the use of secondary care by people with SMI is unknown. We investigated hospital use in people managed in the community with SMI and five common physical long-term conditions: cardiovascular diseases, COPD, cancers, diabetes and liver disease. Methods We performed a systematic review and meta-analysis (Prospero: CRD42020176251) using terms for SMI, physical health conditions and hospitalisation. We included observational studies in adults under the age of 75 with a diagnosis of SMI who were managed in the community and had one of the physical conditions of interest. The primary outcomes were hospital use for all causes, physical health causes and related to the physical condition under study. We performed random-effects meta-analyses, stratified by physical condition. Results We identified 5,129 studies, of which 50 were included: focusing on diabetes (n = 21), cardiovascular disease (n = 19), COPD (n = 4), cancer (n = 3), liver disease (n = 1), and multiple physical health conditions (n = 2). The pooled odds ratio (pOR) of any hospital use in patients with diabetes and SMI was 1.28 (95%CI:1.15–1.44) compared to patients with diabetes alone and pooled hazard ratio was 1.19 (95%CI:1.08–1.31). The risk of 30-day readmissions was raised in patients with SMI and diabetes (pOR: 1.18, 95%CI:1.08–1.29), SMI and cardiovascular disease (pOR: 1.27, 95%CI:1.06–1.53) and SMI and COPD (pOR:1.18, 95%CI: 1.14–1.22) compared to patients with those conditions but no SMI. Conclusion People with SMI and five physical conditions are at higher risk of hospitalisation compared to people with that physical condition alone. Further research is warranted into the combined effects of SMI and physical conditions on longer-term hospital use to better target interventions aimed at reducing inappropriate hospital use and improving disease management and outcomes.
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Affiliation(s)
- Naomi Launders
- Division of Psychiatry, UCL, London, United Kingdom
- * E-mail:
| | | | - Louise Marston
- Department of Primary Care and Population Health, UCL, London, United Kingdom
| | - Gabriele Price
- Health Improvement Directorate, Public Health England, London, United Kingdom
| | - David P. J. Osborn
- Division of Psychiatry, UCL, London, United Kingdom
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, United Kingdom
| | - Joseph F. Hayes
- Division of Psychiatry, UCL, London, United Kingdom
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, London, United Kingdom
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22
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Using Ambulatory Care Sensitive Conditions to Assess Primary Health Care Performance during Disasters: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159193. [PMID: 35954559 PMCID: PMC9367847 DOI: 10.3390/ijerph19159193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/21/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022]
Abstract
Ambulatory care sensitive conditions (ACSCs) are health conditions for which appropriate primary care intervention could prevent hospital admission. ACSC hospitalization rates are a well-established parameter for assessing the performance of primary health care (PHC). Although this indicator has been extensively used to monitor the performance of PHC systems in peacetime, its consideration during disasters has been neglected. The World Health Organization (WHO) has acknowledged the importance of PHC in guaranteeing continuity of care during and after a disaster for avoiding negative health outcomes. We conducted a systematic review to evaluate the extent and nature of research activity on the use of ACSCs during disasters, with an eye toward finding innovative ways to assess the level of PHC function at times of crisis. Online databases were searched to identify papers. A final list of nine publications was retrieved. The analysis of the reviewed articles confirmed that ACSCs can serve as a useful indicator of PHC performance during disasters, with several caveats that must be considered. The reviewed articles cover several disaster scenarios and a wide variety of methodologies showing the connection between ACSCs and health system performance. The strengths and weaknesses of using different methodologies are explored and recommendations are given for using ACSCs to assess PHC performance during disasters.
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23
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16-year trends in asthma hospital admissions in Canada. Ann Allergy Asthma Immunol 2022; 129:475-480.e2. [PMID: 35779843 DOI: 10.1016/j.anai.2022.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asthma hospitalizations declined rapidly in many parts of the world, including Canada, in the 1990s and early 2000s. OBJECTIVE To examine whether the declining trend of asthma hospitalizations persisted in recent years in Canada. METHODS Using the Canadian comprehensive nationwide hospitalization data (2002-2017), we identified hospital admissions with the main International Classification of Diseases codes for asthma. We analyzed sex-specific age-standardized trends in annual hospitalization rates among pediatric (< 19 years) and adult (19+ years) patients. We used change-point analysis to evaluate any substantial changes in the trends in the sex-age groups. RESULTS There were 254,672 asthma-related hospital admissions (59% pediatric, 50% female) during the study period. Among children, age-adjusted annual rates per 100,000 decreased by 55% in females (152-69) and by 60% in males (270-108) from 2002 to 2017. Among adults, the rates decreased by 59% in both sexes (females: 61-25; males: 27-11). Change-point analysis indicated a substantial plateauing of the annual rate in both pediatric (from -15.3 [females] and -25.8 [males] before 2010 to -0.6 [females] and -0.8 [males] after 2010) and adult (from -5.4 [females] and -2.6 [males] before 2008 to -0.6 [females] and -0.2 [males] after 2008) groups. CONCLUSION After a substantial decline in hospital admissions for acute asthma, there has been minimal further decline since 2010 for children and 2008 for adults. In addition to adhering to the contemporary standards of asthma care, novel, disruptive strategies are likely needed to further reduce the burden of asthma.
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24
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Glenister K, Archbold T, Moran A, Kidd D, Wilson S, Disler R. Understanding potentially avoidable hospitalisations in a rural Australian setting from the perspectives of patients and health professionals: a qualitative study and logic model. INTEGRATED HEALTHCARE JOURNAL 2022. [DOI: 10.1136/ihj-2021-000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BackgroundPotentially avoidable hospitalisations (PAHs) are proxy measures of effective primary care at a population level. PAHs are higher in rural and disadvantaged areas. This qualitative study sought a deeper understanding of PAHs for chronic health conditions in a rural context from the perspectives of patients and health professionals, and aimed to develop a logic model for rural health services to identify intervention targets.MethodsPatients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia and local health professionals were invited to participate in interviews in late 2019. Semistructured interviews were recorded, transcribed verbatim and thematically analysed. Themes were mapped against a programme logic model developed in a similar study.Resultspatients and 16 health professionals participated. The logic model encompassed patient level (knowledge, skills, health status), provider level (workforce availability, attributes) and system level (clinical pathways) contexts. These contexts influenced key mechanisms of relationships, continuity of care and capacity to offer services. Outcomes included responsive and timely access to care, improved clinical outcomes and resource use. Themes that did not readily map to the logic model included socioeconomic disadvantage and healthcare costs, which influenced affordability and equity of access.ConclusionPatients’ complex health and social circumstance, health service access and unclear care pathways were strong themes associated with PAH in this rural context. Patient, provider and system contexts influencing key mechanisms and outcomes need to be understood when designing solutions to address PAHs in rural settings. Ideally, interventions should address the cost of healthcare alongside interventions to enhance relationships, continuity of care and capacity to offer services.
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25
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Chen AT, Muralidharan M, Friedman AB. Algorithms Identifying Low Acuity Emergency Department Visits: A Review and Validation Study. Health Serv Res 2022; 57:979-989. [PMID: 35619335 PMCID: PMC9264468 DOI: 10.1111/1475-6773.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low acuity emergency department (ED) visits. DATA SOURCES Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). STUDY DESIGN We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreement using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference. DATA COLLECTION We used 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk. PRINCIPAL FINDINGS We identified 15 papers with an original list of ICD codes used to identify preventable or low acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization. CONCLUSIONS Existing algorithms that identify low acuity ED visits lack congruence and are imperfect predictors of visit acuity.
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Affiliation(s)
- Angela T Chen
- Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Madhavi Muralidharan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ari B Friedman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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26
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Liu X, Seidel JE, McDonald T, Waters N, Patel AB, Shahid R, Bertazzon S, Marshall DA. Rural-Urban Differences in Non-Local Primary Care Utilization among People with Osteoarthritis: The Role of Area-Level Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6392. [PMID: 35681975 PMCID: PMC9180262 DOI: 10.3390/ijerph19116392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 12/04/2022]
Abstract
The utilization of non-local primary care physicians (PCP) is a key primary care indicator identified by Alberta Health to support evidence-based healthcare planning. This study aims to identify area-level factors that are significantly associated with non-local PCP utilization and to examine if these associations vary between rural and urban areas. We examined rural-urban differences in the associations between non-local PCP utilization and area-level factors using multivariate linear regression and geographically weighted regression (GWR) models. Global Moran's I and Gi* hot spot analyses were applied to identify spatial autocorrelation and hot spots/cold spots of non-local PCP utilization. We observed significant rural-urban differences in the non-local PCP utilization. Both GWR and multivariate linear regression model identified two significant factors (median travel time and percentage of low-income families) with non-local PCP utilization in both rural and urban areas. Discontinuity of care was significantly associated with non-local PCP in the southwest, while the percentage of people having university degree was significant in the north of Alberta. This research will help identify gaps in the utilization of local primary care and provide evidence for health care planning by targeting policies at associated factors to reduce gaps in OA primary care provision.
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Affiliation(s)
- Xiaoxiao Liu
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (X.L.); (J.E.S.); (A.B.P.)
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
| | - Judy E. Seidel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (X.L.); (J.E.S.); (A.B.P.)
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Applied Research and Evaluation Services, Alberta Health Services, Edmonton, AB T5G 0B7, Canada
| | - Terrence McDonald
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Nigel Waters
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Civil Engineering, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Environmental Science and Policy, College of Science, George Mason University, Fairfax, VA 22030, USA
| | - Alka B. Patel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (X.L.); (J.E.S.); (A.B.P.)
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Applied Research and Evaluation Services, Alberta Health Services, Edmonton, AB T5G 0B7, Canada
| | - Rizwan Shahid
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Applied Research and Evaluation Services, Alberta Health Services, Edmonton, AB T5G 0B7, Canada
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Stefania Bertazzon
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
- Department of Geography, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Deborah A. Marshall
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (X.L.); (J.E.S.); (A.B.P.)
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB T2N 1N4, Canada; (T.M.); (N.W.); (R.S.); (S.B.)
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Kher S, LeClair AM, Price LL, Terrin N, Kressin N, Hanchate A, Suzukida J, Freund KM. Impact of Insurance Instability and Racial/Ethnic Disparities in Hospitalizations for Patients with Asthma. Ann Am Thorac Soc 2022; 19:867-870. [PMID: 34860640 PMCID: PMC9116335 DOI: 10.1513/annalsats.202106-698rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Sucharita Kher
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
| | - Amy M. LeClair
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
| | - Lori Lyn Price
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
| | - Norma Terrin
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
| | - Nancy Kressin
- Boston University School of MedicineBoston, Massachusetts
| | | | - Jillian Suzukida
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
| | - Karen M. Freund
- Tufts Medical CenterBoston, Massachusetts
- Tufts University School of MedicineBoston, Massachusetts
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28
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Garden G, Usman A, Readman D, Storey L, Wilkinson L, Wilson G, Dening T, Gordon AL, Gladman JRF. Advance care plans in UK care home residents: a service evaluation using a stepped wedge design. Age Ageing 2022; 51:6555262. [PMID: 35348604 PMCID: PMC8963445 DOI: 10.1093/ageing/afac069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. Methods a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. Results About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1–1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. Discussion About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.
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Affiliation(s)
- Gill Garden
- Lincoln Medical School, University of Lincoln, Lincoln, UK.,United Lincolnshire Hospitals Trust, Lincoln, UK
| | - Adeela Usman
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | | | - Graham Wilson
- Lincolnshire Community Health Services Trust, Lincoln, UK
| | - Tom Dening
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Centre-East Midlands (ARC-EM), Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - John R F Gladman
- School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Centre-East Midlands (ARC-EM), Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
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Becker NV, Karmakar M, Tipirneni R, Ayanian JZ. Trends in Hospitalizations for Ambulatory Care-Sensitive Conditions During the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e222933. [PMID: 35297972 PMCID: PMC8931555 DOI: 10.1001/jamanetworkopen.2022.2933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/29/2022] [Indexed: 12/20/2022] Open
Abstract
Importance The association of the COVID-19 pandemic with the quality of ambulatory care is unknown. Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are a well-studied measure of the quality of ambulatory care; however, they may also be associated with other patient-level and system-level factors. Objective To describe trends in hospital admissions for ACSCs in the prepandemic period (March 2019 to February 2020) compared with the pandemic period (March 2020 to February 2021). Design, Setting, and Participants This cross-sectional study of adults enrolled in a commercial health maintenance organization in Michigan included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period. Exposure COVID-19 pandemic (March 2020 to February 2021). Main Outcomes and Measures Adjusted relative risk (aRR) of ACSC hospitalizations and intensive care unit stays for ACSC hospitalizations and adjusted incidence rate ratio of the length of stay of ACSC hospitalizations in the prepandemic (March 2019 to February 2020) vs pandemic (March 2020 to February 2021) periods, adjusted for patient age, sex, calendar month of admission, and county of residence. Results The study population included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period, in which 51.3% of person-months (n = 6 547 231) were for female patients, with a relatively even age distribution between the ages of 24 and 64 years. The relative risk of having any ACSC hospitalization in the pandemic period compared with the prepandemic period was 0.72 (95% CI, 0.69-0.76; P < .001). This decrease in risk was slightly larger in magnitude than the overall reduction in non-ACSC, non-COVID-19 hospitalization rates (aRR, 0.82; 95% CI, 0.81-0.83; P < .001). Large reductions were found in the relative risk of respiratory-related ACSC hospitalizations (aRR, 0.54; 95% CI, 0.50-0.58; P < .001), with non-statistically significant reductions in diabetes-related ACSCs (aRR, 0.91; 95% CI, 0.83-1.00; P = .05) and a statistically significant reduction in all other ACSC hospitalizations (aRR, 0.79; 95% CI, 0.74-0.85; P < .001). Among ACSC hospitalizations, no change was found in the percentage that included an intensive care unit stay (aRR, 0.99; 95% CI, 0.94-1.04; P = .64), and no change was found in the length of stay (adjusted incidence rate ratio, 1.02; 95% CI, 0.98-1.06; P = .33). Conclusions and Relevance In this cross-sectional study of adults enrolled in a large commercial health maintenance organization plan, the COVID-19 pandemic was associated with reductions in both non-ACSC and ACSC hospitalizations, with particularly large reductions seen in respiratory-related ACSCs. These reductions were likely due to many patient-level and health system-level factors associated with hospitalization rates. Further research into the causes and long-term outcomes associated with these reductions in ACSC admissions is needed to understand how the pandemic has affected the delivery of ambulatory and hospital care in the US.
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Affiliation(s)
- Nora V. Becker
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Monita Karmakar
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
| | - Renuka Tipirneni
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - John Z. Ayanian
- Division of General Medicine, University of Michigan Medical School, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Parkinson B, Meacock R, Checkland K, Sutton M. Unseen patterns of preventable emergency care: Emergency department visits for ambulatory care sensitive conditions. J Health Serv Res Policy 2022; 27:232-241. [PMID: 35125033 PMCID: PMC9277334 DOI: 10.1177/13558196211059128] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Admissions for ambulatory care sensitive conditions (ACSCs) are often used to measure potentially preventable emergency care. Visits to emergency departments with ACSCs may also be preventable care but are excluded from such measures if patients are not admitted. We established the extent and composition of this preventable emergency care. Methods We analysed 1,505,979 emergency department visits (5% of the national total) between 1 April 2015 and 31 March 2017 at six hospital Trusts in England, using International Classification of Diseases diagnostic coding. We calculated the number of visits for each ACSC and examined the proportions of these visits that did not result in admission by condition and patient characteristics. Results 11.1% of emergency department visits were for ACSCs. 55.0% of these visits did not result in hospital admission. Whilst the majority of ACSC visits were for acute rather than chronic conditions (59.4% versus 38.4%), acute visits were much more likely to conclude without admission (70.3% versus 33.4%). Younger, more deprived and ethnic minority patients were less likely to be admitted when they visited the emergency department with an ACSC. Conclusions Over half of preventable emergency care is not captured by measures of admissions. The probability of admission at a preventable visit varies substantially between conditions and patient groups. Focussing only on admissions for ACSCs provides an incomplete and skewed picture of the types of conditions and patients receiving preventable care. Measures of preventable emergency care should include visits in addition to admissions.
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Affiliation(s)
- Beth Parkinson
- Health Organisation, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, UK
| | - Rachel Meacock
- Health Organisation, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, UK
| | - Katherine Checkland
- Health Organisation, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Research Group, Centre for Primary Care and Health Services Research, The University of Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Australia
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Orthopaedic Urgent Care Versus the Emergency Department: Cost Implications for Low-energy Fracture Care. J Am Acad Orthop Surg 2022; 30:e371-e374. [PMID: 34844258 DOI: 10.5435/jaaos-d-21-00638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 10/18/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area. METHODS A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted. RESULTS A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period. DISCUSSION These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.
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Saulsberry L, Danahey K, Middlestadt M, O’Leary KJ, Nutescu EA, Chen T, Lee JC, Ruhnke GW, George D, House L, van Wijk XMR, Yeo KTJ, Choksi A, Hartman SW, Knoebel RW, Friedman PN, Rasmussen LV, Ratain MJ, Perera MA, Meltzer DO, O’Donnell PH. Applicability of Pharmacogenomically Guided Medication Treatment during Hospitalization of At-Risk Minority Patients. J Pers Med 2021; 11:1343. [PMID: 34945816 PMCID: PMC8709436 DOI: 10.3390/jpm11121343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022] Open
Abstract
Known disparities exist in the availability of pharmacogenomic information for minority populations, amplifying uncertainty around clinical utility for these groups. We conducted a multi-site inpatient pharmacogenomic implementation program among self-identified African-Americans (AA; n = 135) with numerous rehospitalizations (n = 341) from 2017 to 2020 (NIH-funded ACCOuNT project/clinicaltrials.gov#NCT03225820). We evaluated the point-of-care availability of patient pharmacogenomic results to healthcare providers via an electronic clinical decision support tool. Among newly added medications during hospitalizations and at discharge, we examined the most frequently utilized medications with associated pharmacogenomic results. The population was predominantly female (61%) with a mean age of 53 years (range 19-86). On average, six medications were newly prescribed during each individual hospital admission. For 48% of all hospitalizations, clinical pharmacogenomic information was applicable to at least one newly prescribed medication. Most results indicated genomic favorability, although nearly 29% of newly prescribed medications indicated increased genomic caution (increase in toxicity risk/suboptimal response). More than one of every five medications prescribed to AA patients at hospital discharge were associated with cautionary pharmacogenomic results (most commonly pantoprazole/suboptimal antacid effect). Notably, high-risk pharmacogenomic results (genomic contraindication) were exceedingly rare. We conclude that the applicability of pharmacogenomic information during hospitalizations for vulnerable populations at-risk for experiencing health disparities is substantial and warrants continued prospective investigation.
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Affiliation(s)
- Loren Saulsberry
- Department of Public Health Sciences, The University of Chicago, Chicago, IL 60637, USA
| | - Keith Danahey
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Center for Research Informatics, The University of Chicago, Chicago, IL 60637, USA
| | - Merisa Middlestadt
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
| | - Kevin J. O’Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Edith A. Nutescu
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, IL 60612, USA;
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois Chicago, Chicago, IL 60612, USA
| | - Thomas Chen
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - James C. Lee
- Department of Pharmacy Practice, University of Illinois Chicago, Chicago, IL 60612, USA;
| | - Gregory W. Ruhnke
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - David George
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
| | - Larry House
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
| | - Xander M. R. van Wijk
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Kiang-Teck J. Yeo
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Pathology, The University of Chicago, Chicago, IL 60637, USA
- Advanced Technology Clinical Laboratory, The University of Chicago, Chicago, IL 60637, USA
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Anish Choksi
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Seth W. Hartman
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Randall W. Knoebel
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Department of Pharmacy, The University of Chicago, Chicago, IL 60637, USA;
| | - Paula N. Friedman
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - Luke V. Rasmussen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Mark J. Ratain
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
| | - Minoli A. Perera
- Center for Pharmacogenomics, Department of Pharmacology, Northwestern University, Chicago, IL 60611, USA; (P.N.F.); (M.A.P.)
| | - David O. Meltzer
- Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (T.C.); (G.W.R.); (D.O.M.)
| | - Peter H. O’Donnell
- Center for Personalized Therapeutics, The University of Chicago, Chicago, IL 60637, USA; (K.D.); (M.M.); (D.G.); (L.H.); (X.M.R.v.W.); (K.-T.J.Y.); (M.J.R.); (P.H.O.)
- Department of Medicine, The University of Chicago, Chicago, IL 60637, USA; (S.W.H.); (R.W.K.)
- Committee on Clinical Pharmacology and Pharmacogenomics, The University of Chicago, Chicago, IL 60637, USA
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The Cost Consequences of the Gold Coast Integrated Care Programme. Int J Integr Care 2021; 21:9. [PMID: 34611459 PMCID: PMC8447978 DOI: 10.5334/ijic.5542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/02/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.
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Gettel CJ, Venkatesh AK, Leo-Summers LS, Murphy TE, Gahbauer EA, Hwang U, Gill TM. A Longitudinal Analysis of Functional Disability, Recovery, and Nursing Home Utilization After Hospitalization for Ambulatory Care Sensitive Conditions Among Community-Living Older Persons. J Hosp Med 2021; 16:469-475. [PMID: 34328835 PMCID: PMC8340961 DOI: 10.12788/jhm.3669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/21/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND/OBJECTIVE Hospitalizations for ambulatory care sensitive conditions (ACSCs) are considered potentially preventable. With little known about the functional outcomes of older persons after ACSC-related hospitalizations, our objectives were to describe: (1) the 6-month course of postdischarge functional disability, (2) the cumulative monthly probability of functional recovery, and (3) the cumulative monthly probability of incident nursing home (NH) admission. METHODS The analytic sample included 251 ACSC-related hospitalizations from a cohort of 754 nondisabled, community-living persons aged 70 years and older who were interviewed monthly for up to 19 years. Patient-reported disability scores in basic, instrumental, and mobility activities ranged from 0 to 13. Functional recovery was defined as returning within 6 months of discharge to a total disability score less than or equal to that immediately preceding hospitalization. RESULTS The mean age was 85.1 years, and the mean disability score was 5.4 in the month prior to the ACSC-related hospitalization. After the ACSC-related hospitalization, total disability scores peaked at month 1 and improved modestly over the next 5 months, but remained greater than the pre-hospitalization score. Functional recovery was achieved by 70% of patients, and incident NH admission was experienced by 50% within 6 months after the 251 ACSC-related hospitalizations. CONCLUSIONS During the 6 months after an ACSC-related hospitalization, older persons exhibited total disability scores that were higher than those immediately preceding hospitalization, with 3 of 10 not achieving functional recovery and half experiencing incident NH admission. These findings provide evidence that older persons experience clinically meaningful adverse patient-reported outcomes after ACSC-related hospitalizations.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Corresponding Author: Cameron J Gettel, MD; ; Telephone: 203-785-4148; Twitter: @CameronGettel
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Linda S Leo-Summers
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terrence E Murphy
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Evelyne A Gahbauer
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Geriatrics Research, Education, and Clinical Center, James J Peters VAMC, Bronx, New York
| | - Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Moss C, Sutton M, Cheraghi-Sohi S, Sanders C, Allen T. Comparative 4-year risk and type of hospital admission among homeless and housed emergency department attendees: longitudinal study of hospital records in England 2013-2018. BMJ Open 2021; 11:e049811. [PMID: 34312208 PMCID: PMC8314693 DOI: 10.1136/bmjopen-2021-049811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES People experiencing homelessness are frequent users of secondary care. Currently, there is no study of potentially preventable admissions for homeless patients in England. We aim to estimate the number of potentially preventable hospital admissions for homeless patients and compare to housed patients with similar characteristics. DESIGN Retrospective matched cohort study. SETTING Hospitals in England. PARTICIPANTS 16 161 homeless patients and 74 780 housed patients aged 16-75 years who attended an emergency department (ED) in England in 2013/2014, matched on the basis of age, sex, ED attended and primary diagnosis. PRIMARY AND SECONDARY OUTCOME MEASURES Annual counts of admissions, emergency admissions, ambulatory care-sensitive (ACS) emergency admissions, acute ACS emergency admissions and chronic ACS emergency admissions over the following 4 years (2014/2015-2017/2018). We additionally compare the prevalence of specific ACS conditions for homeless and housed patients. RESULTS Mean admissions per 1000 patients per year were 470 for homeless patients and 230 for housed patients. Adjusted for confounders, annual admissions were 1.79 times higher (incident rate ratio (IRR)=1.79; 95% CI 1.69 to 1.90), emergency admissions 2.08 times higher (IRR=2.08; 95% CI 1.95 to 2.21) and ACS admissions 1.65 times higher (IRR=1.65; 95% CI 1.51 to 1.80), compared with housed patients. The effect was greater for acute (IRR=1.78; 95% CI 1.64 to 1.93) than chronic (IRR=1.45; 95% CI 1.27 to 1.66) ACS conditions. ACS conditions that were relatively more common for homeless patients were cellulitis, convulsions/epilepsy and chronic angina. CONCLUSIONS Homeless patients use hospital services at higher rates than housed patients, particularly emergency admissions. ACS admissions of homeless patients are higher which suggests some admissions may be potentially preventable with improved access to primary care. However, these admissions comprise a small share of total admissions.
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Affiliation(s)
- Charlie Moss
- Health Organisation, Policy and Economics, Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sudeh Cheraghi-Sohi
- NIHR Greater Manchester Patient Safety Translational Research Centre, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Caroline Sanders
- NIHR Greater Manchester Patient Safety Translational Research Centre, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, School of Health Sciences, The University of Manchester, Manchester, UK
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Petersen J, Kandt J, Longley P. Ethnic disparities in preventable hospitalisation in England: an analysis of 916 375 emergency admissions. J Epidemiol Community Health 2021; 76:85-91. [PMID: 34168054 PMCID: PMC8666822 DOI: 10.1136/jech-2020-216005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 06/14/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To study ethnic inequalities in ambulatory care sensitive conditions (ACSC) in England. DESIGN Observational study of inpatient hospital admission database enhanced with ethnicity coding of patient surnames. The primary diagnosis of the first episode in spells with emergency admission were coded with definitions for acute ACSC, chronic ACSC and vaccine-preventable diseases. SETTING National Health Service England. PARTICIPANTS 916 375 ACSC emergency admissions in 7 39 618 patients were identified between April 2011 and March 2012. MAIN OUTCOME MEASURES ORs of ACSC for each ethnic group relative to the White British majority group adjusted for age, sex and area deprivation. RESULTS Acute ACSC admission risk adjusted for age and sex was particularly high among Other (OR 1.73; 95% CI 1.69 to 1.77) and Pakistani (1.51; 95% CI 1.48 to 1.54) compared with White British patients. For chronic ACSC, high risk was found among Other (2.02; 95% CI 1.97 to 2.08), Pakistani (2.07; 95% CI 2.02 to 2.12) and Bangladeshi (1.36; 95% CI 1.30 to 1.42). For vaccine-preventable diseases, other (2.42; 95% CI 2.31 to 2.54), Pakistani (1.94; 95% CI 1.85 to 2.04), Bangladeshi (1.48; 95% CI 1.36 to 1.62), Black African (1.45; 95% CI 1.36 to 1.54) and white other (1.38; 95% CI 1.33 to 1.43) groups. Elevated risk was only partly explained in analyses also adjusting for area deprivation. CONCLUSIONS ACSC admission was especially high among individuals of Bangladeshi, Pakistani, Black African, white other or other background with up to twofold differences compared with the white British group. This suggests that these ethnic groups are not receiving optimal primary care.
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Affiliation(s)
| | - Jens Kandt
- The Bartlett Centre for Advanced Spatial Analysis (CASA), University College London, London, UK
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Nishioka D, Saito J, Ueno K, Kondo N. Non-financial social determinants of diabetes among public assistance recipients in Japan: A cohort study. J Diabetes Investig 2021; 12:1104-1111. [PMID: 33047513 PMCID: PMC8169356 DOI: 10.1111/jdi.13435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/19/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022] Open
Abstract
AIMS/INTRODUCTION Poverty is an important social determinant of diabetes. Poverty is a multidimensional concept including non-financial difficulties, such as social isolation and exclusion from communities. Many countries provide financial social assistance programs for those in need. This study aimed to explore non-financial social determinants of diabetes among public assistance recipients in Japan, by using linkage data of two municipal public assistance databases and medical assistance claim data. MATERIALS AND METHODS We carried out a retrospective cohort study. Public assistance is provided to households below the poverty line to ensure their income security. We extracted recipients' sociodemographic factors of January 2016 (household number and employment status as non-financial social determinants of diabetes) and identified the incidence of diabetes diagnosis until December 2016 as the outcome. RESULTS We included the data of 2,698 younger individuals (aged <65 years) and 3,019 older individuals (aged >65 years). A multivariable Poisson regression, with a robust standard error estimator, showed that among 2,144 younger recipients at risk, unemployment and living alone were slightly associated with 1-year cumulative incidence of diabetes diagnosis (adjusted incidence ratio 1.20, 95% confidence interval 0.93-1.54 and adjusted incidence ratio 1.15, 95% confidence interval 0.89-1.48, respectively). Among 2,181 older recipients at risk, there was no strong association between their sociodemographic factors and incidence of diabetes diagnosis. CONCLUSIONS Unemployment and living alone might be additional risk factors for diabetes among younger public assistance recipients. Multidimensional supports assuring financial and non-financial securities are required to prevent diabetes among people living in poverty.
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Affiliation(s)
- Daisuke Nishioka
- Department of Health and Social BehaviorGraduate School of MedicineThe University of TokyoTokyoJapan
- Department of Social EpidemiologyGraduate School of Medicine and School of Public HealthKyoto UniversityKyotoJapan
| | - Junko Saito
- Behavioral Science DivisionBehavioral Sciences and Survivorship Research GroupCenter for Public Health SciencesNational Cancer Center JapanTokyoJapan
| | - Keiko Ueno
- Department of Health and Social BehaviorGraduate School of MedicineThe University of TokyoTokyoJapan
| | - Naoki Kondo
- Department of Health and Social BehaviorGraduate School of MedicineThe University of TokyoTokyoJapan
- Department of Social EpidemiologyGraduate School of Medicine and School of Public HealthKyoto UniversityKyotoJapan
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Walsh ME, Cronin S, Boland F, Ebell MH, Fahey T, Wallace E. Geographical variation of emergency hospital admissions for ambulatory care sensitive conditions in older adults in Ireland 2012-2016. BMJ Open 2021; 11:e042779. [PMID: 33952537 PMCID: PMC8103372 DOI: 10.1136/bmjopen-2020-042779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Ambulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation. DESIGN Repeated cross-sectional study. SETTING 34 public hospitals in the Ireland. PARTICIPANTS Adults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia). PRIMARY OUTCOME MEASURE Age and sex standardised emergency admission rates (SARs) per 1000 older adults. ANALYSIS Age and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables. RESULTS Over time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7-50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: -2.2 (-3.4 to -0.9, p<0.01)), lower GP supply (adjusted coefficient: -5.5 (-8.2 to -2.9, p<0.01)) and higher geriatrician supply (adjusted coefficient: 3.7 (0.5 to 6.9, p=0.02)) were associated with higher SARs. CONCLUSIONS Future research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.
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Affiliation(s)
- Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sinead Cronin
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark H Ebell
- Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Liu X, Barber CEH, Katz S, Homik J, Bertazzon S, Patel AB, Robert J, Smith C, Mosher D, Marshall DA. Geographic Variation in the Prevalence of Rheumatoid Arthritis in Alberta, Canada. ACR Open Rheumatol 2021; 3:324-332. [PMID: 33793090 PMCID: PMC8126758 DOI: 10.1002/acr2.11251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Timely access to rheumatologists remains a challenge in Alberta, a Canadian province with vast rural areas, whereas rheumatologists are primarily clustered in metro areas. To address the goal of timely and equitable access to rheumatoid arthritis (RA) care, health planners require information at the regional and local level to determine the RA prevalence and the associated health care needs. METHODS Using Alberta Health administrative databases, we identified RA-prevalent cases (April 1, 2015-March 31, 2016) on the basis of a validated case definition. Age- and sex-standardized prevalence rates per 1000 population members and the standardized rates ratio (SRR) were calculated. We applied Global Moran's I and Gi* hotspot analysis using three different weight matrices to explore the geospatial pattern of RA prevalence in Alberta. RESULTS Among 38 350 RA cases (68% female; n = 26 236), the prevalence rate was 11.81 cases per 1000 population members (95% confidence interval [CI] 11.80-11.81) after age and sex standardization. Approximately 60% of RA cases resided in metro (Calgary and Edmonton) and moderate metro areas. The highest rate was observed in rural areas (14.46; 95% CI 14.45-14.47; SRR 1.28), compared with the lowest in metro areas (10.69; 95% CI 10.68-10.69; SRR 0.82). The RA prevalence across local geographic areas ranged from 4.7 to 30.6 cases. The Global Moran's I index was 0.15 using three different matrices (z-score 3.96-4.24). We identified 10 hotspots in the south and north rural areas and 18 cold spots in metro and moderate metro Calgary. CONCLUSION The findings highlight notable rural-urban variation in RA prevalence in Alberta. Our findings can inform strategies aimed at reducing geographic disparities by targeting areas with high health care needs.
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Affiliation(s)
| | - Claire E. H. Barber
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research CanadaRichmondBritish ColumbiaCanada
| | | | | | | | - Alka B. Patel
- University of Calgary, Calgary, Alberta, Canada, and Alberta Health ServicesEdmontonAlbertaCanada
| | - Jill Robert
- Alberta Health ServicesEdmontonAlbertaCanada
| | | | | | - Deborah A. Marshall
- University of Calgary, Calgary, Alberta, Canada, and Arthritis Research CanadaRichmondBritish ColumbiaCanada
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Home Healthcare Clinical Notes Predict Patient Hospitalization and Emergency Department Visits. Nurs Res 2021; 69:448-454. [PMID: 32852359 DOI: 10.1097/nnr.0000000000000470] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND About 30% of home healthcare patients are hospitalized or visit an emergency department (ED) during a home healthcare (HHC) episode. Novel data science methods are increasingly used to improve identification of patients at risk for negative outcomes. OBJECTIVES The aim of the study was to identify patients at heightened risk hospitalization or ED visits using HHC narrative data (clinical notes). METHODS This study used a large database of HHC visit notes (n = 727,676) documented for 112,237 HHC episodes (89,459 unique patients) by clinicians of the largest nonprofit HHC agency in the United States. Text mining and machine learning algorithms (Naïve Bayes, decision tree, random forest) were implemented to predict patient hospitalization or ED visits using the content of clinical notes. Risk factors associated with hospitalization or ED visits were identified using a feature selection technique (gain ratio attribute evaluation). RESULTS Best performing text mining method (random forest) achieved good predictive performance. Seven risk factors categories were identified, with clinical factors, coordination/communication, and service use being the most frequent categories. DISCUSSION This study was the first to explore the potential contribution of HHC clinical notes to identifying patients at risk for hospitalization or an ED visit. Our results suggest that HHC visit notes are highly informative and can contribute significantly to identification of patients at risk. Further studies are needed to explore ways to improve risk prediction by adding more data elements from additional data sources.
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Longman J, Johnston J, Ewald D, Gilliland A, Burke M, Mutonga T, Passey M. What could prevent chronic condition admissions assessed as preventable in rural and metropolitan contexts? An analysis of clinicians' perspectives from the DaPPHne study. PLoS One 2021; 16:e0244313. [PMID: 33411717 PMCID: PMC7790391 DOI: 10.1371/journal.pone.0244313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 12/07/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Reducing potentially preventable hospitalisations (PPH) is a priority for health services. This paper describes the factors that clinicians perceived contributed to preventable admissions for angina, diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD), and what they considered might have been done in the three months leading up to an admission to prevent it. METHODS The study was conducted in a rural and a metropolitan health district in NSW, Australia. Expert Panels reviewed detailed case reports to assess preventability. For those admissions identified as preventable, comments from clinicians indicating what they perceived could have made a difference and/or been done differently to prevent each of the preventable admissions were analysed qualitatively. RESULTS 148 (46%) of 323 admissions were assessed as preventable. Across the two districts, the most commonly identified groups of contributing factors to preventable admissions were: 'Systems issues: Community based services missing or inadequate or not referred to'; 'Patient issues: Problems with adherence/self-management'; and 'Clinician issues: GP care inadequate'. In some instances, important differences drove these groups of factors. For example, in the rural district 'Systems issues: Community based services missing or inadequate or not referred to' was largely driven by social and welfare support services missing/inadequate/not referred to, whereas in the metropolitan district it was largely driven by community nursing, allied health, care coordination or integrated care services missing/inadequate/not referred to. Analyses revealed the complexity of system, clinician and patient factors contributing to each admission. Admissions for COPD (rural) and CHF (metropolitan) admissions showed greatest complexity. DISCUSSION AND CONCLUSION These findings suggest preventability of individual admissions is complex and context specific. There is no single, simple solution likely to reduce PPH. Rather, an approach addressing multiple factors is required. This need for comprehensiveness may explain why many programs seeking to reduce PPH have been unsuccessful.
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Affiliation(s)
- Jo Longman
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
- * E-mail:
| | - Jennifer Johnston
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
| | - Dan Ewald
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
- North Coast Primary Health Network, Ballina, NSW, Australia
| | | | - Michael Burke
- School of Medicine, The University of Sydney, Sydney, NSW, Australia
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Tabeth Mutonga
- Mt Druitt Community Health Centre, Western Sydney Local Health District, Mt Druitt, NSW, Australia
| | - Megan Passey
- University Centre for Rural Health, The University of Sydney, Lismore, NSW, Australia
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Johnston J, Longman J, Ewald D, King J, Das S, Passey M. Study of potentially preventable hospitalisations (PPH) for chronic conditions: what proportion are preventable and what factors are associated with preventable PPH? BMJ Open 2020; 10:e038415. [PMID: 33168551 PMCID: PMC7654103 DOI: 10.1136/bmjopen-2020-038415] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The proportion of potentially preventable hospitalisations (PPH) which are actually preventable is unknown, and little is understood about the factors associated with individual preventable PPH. The Diagnosing Potentially Preventable Hospitalisations (DaPPHne) Study aimed to determine the proportion of PPH for chronic conditions which are preventable and identify factors associated with chronic PPH classified as preventable. SETTING Three hospitals in NSW, Australia. PARTICIPANTS Community-dwelling patients with unplanned hospital admissions between November 2014 and June 2017 for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes complications or angina pectoris. Data were collected from patients, their general practitioners (GPs) and hospital records. OUTCOME MEASURES Assessments of the preventability of each admission by an Expert Panel. RESULTS 323 admissions were assessed for preventability: 46% (148/323) were assessed as preventable, 30% (98/323) as not preventable and 24% (77/323) as unclassifiable. Statistically significant differences in proportions preventable were found between the three study sites (29%; 47%; 58%; p≤0.001) and by primary discharge diagnosis (p≤0.001).Significant predictors of an admission being classified as preventable were: study site; final principal diagnosis of CHF; fewer diagnoses on discharge; shorter hospital stay; GP diagnosis of COPD; GP consultation in the last 12 months; not having had a doctor help make the decision to go to hospital; not arriving by ambulance; patient living alone; having someone help with medications and requiring help with daily tasks. CONCLUSIONS That less than half the chronic PPH were assessed as preventable, and the range of factors associated with preventability, including site and discharge diagnosis, are important considerations in the validity of PPH as an indicator. Opportunities for interventions to reduce chronic PPH include targeting patients with CHF and COPD, and the provision of social welfare and support services for patients living alone and those requiring help with daily tasks and medication management.
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Affiliation(s)
- Jennifer Johnston
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Jo Longman
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Dan Ewald
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Jonathan King
- The Kirby Institute, Kensington, New South Wales, Australia
| | - Sumon Das
- Child Health Division, Menzies School of Health Research, Casuarina, Northern Territory, Australia
| | - Megan Passey
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
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Peters GA, Ordoobadi AJ, Cash RE, Wong ML, Avillach P, Camargo CA. Association of Affordable Care Act Implementation With Ambulance Utilization for Asthma Emergencies in New York City, 2008-2018. JAMA Netw Open 2020; 3:e2025586. [PMID: 33175178 PMCID: PMC7658734 DOI: 10.1001/jamanetworkopen.2020.25586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Emergency medical services (EMS) are an essential component of the health care system, but the effect of insurance expansion on EMS call volume remains unclear. OBJECTIVE This study investigated the association between health insurance expansion and EMS dispatches for asthma, an ambulatory care-sensitive condition. We hypothesized that insurance expansion under the Patient Protection and Affordable Care Act (ACA) would be associated with decreased EMS dispatches for asthma emergencies. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined 14 865 267 ambulance calls dispatched within New York City from 2008 to 2018, including 217 303 calls for asthma-related emergencies, and used interrupted time series analysis to study the change in the annual incidence of EMS dispatches for asthma emergencies after implementation of the ACA. Multivariable linear regression examined the association between the uninsured rate and the incidence of asthma-related dispatches, controlling for population demographic characteristics and air quality index. EXPOSURES Implementation of ACA on January 1, 2014. MAIN OUTCOMES AND MEASURES Incidence of EMS dispatches for asthma emergencies per 100 000 population per year (ie, asthma EMS dispatch rate) as classified by the 911 call-taker. RESULTS In this study of 217 303 EMS dispatches for asthma-related emergencies, there was a decrease in the asthma EMS dispatch rate after implementation of the ACA, from a mean (SD) of 261 (24) dispatches per 100 000 population per year preintervention to 211 (47) postintervention (P = .047). This decrease in asthma EMS dispatch rate after ACA implementation was significant on interrupted time series analysis. Prior to 2014, the annual asthma EMS dispatch rate was increasing by 11.8 calls per 100 000 population per year (95% CI, 6.1 to 17.4). After ACA implementation, the asthma EMS dispatch rate decreased annually by 28.5 calls per 100 000 population per year (95% CI, -37.6 to -19.3), a significant change in slope from the preintervention period (P < .001). Multivariable linear regression, controlling for percentage of individuals younger than age 18 years, degree of racial/ethnic diversity, median household income, and air quality index, found that a 1% decrease in the citywide uninsured rate was associated with a decrease of 98.9 asthma dispatches per 100 000 population per year (95% CI, 5.72-192.10; P = .04). CONCLUSIONS AND RELEVANCE Insurance expansion within New York City under the ACA was associated with a significant reduction in the asthma EMS dispatch rate. Insurance expansion may be a viable method to reduce EMS utilization for ambulatory care-sensitive conditions such as asthma.
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Affiliation(s)
- Gregory A. Peters
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Rebecca E. Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew L. Wong
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Paul Avillach
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Liu X, Shahid R, Patel AB, McDonald T, Bertazzon S, Waters N, Seidel JE, Marshall DA. Geospatial patterns of comorbidity prevalence among people with osteoarthritis in Alberta Canada. BMC Public Health 2020; 20:1551. [PMID: 33059639 PMCID: PMC7559790 DOI: 10.1186/s12889-020-09599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 09/23/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Knowledge of geospatial pattern in comorbidities prevalence is critical to an understanding of the local health needs among people with osteoarthritis (OA). It provides valuable information for targeting optimal OA treatment and management at the local level. However, there is, at present, limited evidence about the geospatial pattern of comorbidity prevalence in Alberta, Canada. METHODS Five administrative health datasets were linked to identify OA cases and comorbidities using validated case definitions. We explored the geospatial pattern in comorbidity prevalence at two standard geographic areas levels defined by the Alberta Health Services: descriptive analysis at rural-urban continuum level; spatial analysis (global Moran's I, hot spot analysis, cluster and outlier analysis) at the local geographic area (LGA) level. We compared area-level indicators in comorbidities hotspots to those in the rest of Alberta (non-hotspots). RESULTS Among 359,638 OA cases in 2013, approximately 60% of people resided in Metro and Urban areas, compared to 2% in Rural Remote areas. All comorbidity groups exhibited statistically significant spatial autocorrelation (hypertension: Moran's I index 0.24, z score 4.61). Comorbidity hotspots, except depression, were located primarily in Rural and Rural Remote areas. Depression was more prevalent in Metro (Edmonton-Abbottsfield: 194 cases per 1000 population, 95%CI 192-195) and Urban LGAs (Lethbridge-North: 169, 95%CI 168-171) compared to Rural areas (Fox Creek: 65, 95%CI 63-68). Comorbidities hotspots included a higher percentage of First Nations or Inuit people. People with OA living in hotspots had lower socioeconomic status and less access to care compared to non-hotspots. CONCLUSIONS The findings highlight notable rural-urban disparities in comorbidities prevalence among people with OA in Alberta, Canada. Our study provides valuable evidence for policy and decision makers to design programs that ensure patients with OA receive optimal health management tailored to their local needs and a reduction in current OA health disparities.
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Affiliation(s)
- Xiaoxiao Liu
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Rizwan Shahid
- Department of Geography, University of Calgary, Calgary, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Alka B Patel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Terrence McDonald
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Nigel Waters
- Department of Geography, University of Calgary, Calgary, Canada
| | - Judy E Seidel
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada
- Applied Research and Evaluation Services, Alberta Health Services, Calgary, Canada
| | - Deborah A Marshall
- Department of Community Health Science, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, HRIC Building, Room 3C58, Calgary, AB, T2N 4Z6, Canada.
- McCaig Bone and Joint Health Institute, University of Calgary, Calgary, Canada.
- O'Brien Institute for Public Health, University of Calgary, Calgary, Canada.
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Grigoroglou C, Munford L, Webb R, Kapur N, Doran T, Ashcroft D, Kontopantelis E. Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England. BMJ Open 2020; 10:e036046. [PMID: 32907897 PMCID: PMC7482460 DOI: 10.1136/bmjopen-2019-036046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world's largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme. SETTING We obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics. RESULTS Hospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition. CONCLUSION Spatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.
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Affiliation(s)
- Christos Grigoroglou
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Luke Munford
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health Organisation, Policy and Economics, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Roger Webb
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Centre for Mental Health and Safety, Division of Psychology & Mental Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Navneet Kapur
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Suicide Prevention, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health Trust, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Darren Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine & Health, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, Greater Manchester, UK
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Partanen VM, Arffman M, Manderbacka K, Keskimäki I. Mortality related to ambulatory care sensitive hospitalisations in Finland. Scand J Public Health 2020; 48:839-846. [PMID: 32755271 DOI: 10.1177/1403494820944722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims: Hospitalisations for ambulatory care sensitive conditions are used as an outcome indicator of access to and quality of primary care. Evidence on mortality related to these hospitalisations is scarce. This study analysed the effect of ambulatory care sensitive condition hospitalisations to subsequent mortality and time or geographical trends in the mortality indicating variations in ambulatory care sensitive conditions outcomes. Methods: This retrospective cohort study used individual-level data from national registers concerning ambulatory care sensitive condition hospitalisations. Crude and age-adjusted 365-day mortality rates for the first ambulatory care sensitive condition-related admission were calculated for vaccine-preventable, acute, and chronic ambulatory care sensitive conditions separately, and for three time periods stratified by gender. The mortality rates were also compared to mortality in the general Finnish population to assess the excess mortality related to ambulatory care sensitive condition hospitalisations. Results: The data comprised a total of 712,904 ambulatory care sensitive condition hospital admissions with the crude 365-day mortality rate of 14.2 per 100 person-years. Mortality for those hospitalised for vaccine-preventable conditions was approximately 10-fold compared to the general population and four-fold in chronic and acute conditions. Of the 10 most common ambulatory care sensitive conditions, bacterial pneumonia and influenza and congestive heart failure were associated with highest age-standardised mortality rates. Conclusions: Hospitalisations for ambulatory care sensitive conditions were shown to be associated with excess mortality in patients compared to the general population. Major differences in mortality were found between different types of ambulatory care sensitive condition admissions. There were also minor differences in mortality between hospital districts. These differences are important to consider when using preventable hospital admissions as an indicator of primary care performance.
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Affiliation(s)
| | - Martti Arffman
- Service System Research, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Kristiina Manderbacka
- Service System Research, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Ilmo Keskimäki
- Service System Research, Finnish Institute for Health and Welfare, Helsinki, Finland.,Faculty of Social Sciences, Tampere University, Tampere, Finland
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Parkinson B, Meacock R, Checkland K, Sutton M. Clarifying the concept of avoidable emergency department attendance. J Health Serv Res Policy 2020; 26:68-73. [PMID: 32517553 PMCID: PMC7734604 DOI: 10.1177/1355819620921894] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Emergency department attendances are rising in several countries. Many of the policies aimed at reducing emergency department attendances are based on the assumption that a proportion of current utilization is ‘avoidable’ and therefore could be reduced. In considering how to achieve this aim, it is important to first understand the problem. In this essay, we review the literature on the concept and identification of avoidable emergency department attendances in England. We identified three areas of inconsistency surrounding avoidable emergency department attendances: the terminology, the underlying definition, and the method used to identify avoidable attendances. We offer a more nuanced definition which may better support action to reduce emergency department activity. Recognizing that there are different types of undesirable utilization which vary by underlying causes and potential solutions will aid policy makers in identifying areas where policies targeting reductions in emergency department attendances would best be directed.
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Affiliation(s)
- Beth Parkinson
- PhD student in Health Economics, Health Organisation, Policy and Economics, The University of Manchester, UK
| | - Rachel Meacock
- Senior Lecturer in Health Economics, Health Organisation, Policy and Economics, The University of Manchester, UK
| | - Katherine Checkland
- Professor of Health Policy and Primary Care, Health Organisation, Policy and Economics, The University of Manchester, UK
| | - Matt Sutton
- Professor of Health Economics, Health Organisation, Policy and Economics, School of Health Sciences, The University of Manchester, UK
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Watase T, Jablonowski K, Sabbatini A. Prospective analysis of alternative services and cost savings of avoidable admissions from the ED. Am J Emerg Med 2020; 38:624-628. [DOI: 10.1016/j.ajem.2019.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 10/31/2019] [Accepted: 11/01/2019] [Indexed: 11/25/2022] Open
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Welberry H, Barr ML, Comino EJ, Harris-Roxas BF, Harris E, Dutton S, Jackson T, Donnelly D, Harris MF. Do general practice management and/or team care arrangements reduce avoidable hospitalisations in Central and Eastern Sydney, Australia? BMC Health Serv Res 2019; 19:811. [PMID: 31699091 PMCID: PMC6836396 DOI: 10.1186/s12913-019-4663-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 10/21/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. METHODS This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006-2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. RESULTS Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. CONCLUSIONS The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.
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Affiliation(s)
- Heidi Welberry
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
| | - Margo Linn Barr
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
| | - Elizabeth J. Comino
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
| | - Ben F. Harris-Roxas
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
| | - Elizabeth Harris
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
- Health Equity Research and Development Unit, Sydney Local Health District, NSW, Level 9, King George V Building, PO Box 374, Camperdown, NSW 2050 Australia
| | - Shona Dutton
- The Royal Australian & New Zealand College of Radiologists, Level 9, 51 Druitt Street, Sydney, NSW 2000 Australia
- Central and Eastern Sydney Primary Health Network, Tower A, L5, 201 Coward Street, Mascot, NSW 2020 Australia
| | - Tony Jackson
- South Eastern Sydney Local Health District, NSW Health, District Executive Unit, Locked Mail Bag 21, Tarren Point, NSW 2229 Australia
| | - Debra Donnelly
- Sydney Local Health District, NSW Health, Level 11, KGV Building, Missenden Road, Camperdown, NSW 2050 Australia
| | - Mark Fort Harris
- Centre for Primary Health Care and Equity, Faculty of Medicine, University of New South Wales, Level 3, AGSM Building, Sydney, NSW 2052 Australia
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Maust DT, Kim HM, Chiang C, Langa KM, Kales HC. Predicting Risk of Potentially Preventable Hospitalization in Older Adults with Dementia. J Am Geriatr Soc 2019; 67:2077-2084. [PMID: 31211418 PMCID: PMC6896207 DOI: 10.1111/jgs.16030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Reducing potentially preventable hospitalization (PPH) among older adults with dementia is a goal of Healthy People 2020, yet no tools specifically identify patients with dementia at highest risk. The objective was to develop a risk prediction model to identify older adults with dementia at high imminent risk of PPH. DESIGN A 30-day risk prediction model was developed using multivariable logistic regression. Patients from fiscal years (FY) 2009 to 2011 were split into development and validation cohorts; FY2012 was used for prediction. SETTING Community-dwelling older adults (≥65 years of age) with dementia who received care through the Veterans Health Administration. PARTICIPANTS There were 1 793 783 participants. MEASUREMENTS Characteristics associated with hospitalization risk were (1) age and other demographic factors; (2) outpatient, emergency department, and inpatient utilization; (3) medical and psychiatric diagnoses; and (4) prescribed medication use including changes to psychotropic medications (eg, initiation or dosage increase). Model discrimination was determined by the C statistic for each of the three cohorts. Finally, to determine whether predicted 30-day risk strata were stable over time, the observed PPH rate was calculated out to 1 year. RESULTS In the development cohort, .6% of patients experienced PPH within 30 days. The C statistic for the development cohort was .83 (95% confidence interval [CI] = .83-.84) and .83 in the prediction cohort (95% CI = .82-.84). Patients in the top 10% of predicted 30-day PPH risk accounted for more than 50% of 30-day PPH admissions in all three cohorts. In addition, those predicted to be at elevated 30-day risk remained at higher risk throughout a year of follow-up. CONCLUSION It is possible to identify older adults with dementia at high risk of imminent PPH, and their risk remains elevated for an entire year. Given the negative outcomes associated with acute hospitalization for those with dementia, healthcare systems and providers may be able to engage these high-risk patients proactively to avoid unnecessary hospitalization. J Am Geriatr Soc 67:2077-2084, 2019.
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Affiliation(s)
- Donovan T. Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - H. Myra Kim
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Claire Chiang
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Kenneth M. Langa
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Helen C. Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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