Avoidable hospitalizations in Switzerland: a small area analysis on regional variation, density of physicians, hospital supply and rurality

Twenty-year trends of potentially avoidable hospitalizations for hypertension in Switzerland

We assessed the trends, characteristics, and consequences of potentially avoidable hospitalizations (PAH) for hypertension in Switzerland, for the period 1998 to 2018. Data from 117,507 hospitalizations (62.1% women), minimum age 20 years. Hospitalizations with hypertension as the main cause for admission were eligible. PAH for hypertension was defined according to the Organization for Economic Cooperation and Development criteria. The age-standardized rates of PAH for hypertension increased from 43 in 1998 to 81 per 100,000 in 2004, to decrease to 57 per 100,000 inhabitants in 2018. Compared to non-PAH, patients with PAH for hypertension were younger, more frequently women (66.9% vs. 56.7%), non-Swiss nationals (15.9% vs. 10.9%), were more frequently admitted as an emergency (78.9% vs. 59.5%), and by the patient's initiative (33.1% vs. 14.1%). Patients with PAH had also fewer comorbidities, as per the Charlson's index. Patients with PAH for hypertension were more frequently hospitalized in a semi-private or private setting, stayed less frequently in the intensive care unit (4.6% vs. 7.3%), were discharged more frequently home (91.4% vs. 73.0%), and had a shorter length of stay than patients with non-PAH for hypertension: median and [interquartile range] 5 [3-8] vs. 9 [4-15] days. In 2018, the total costs of PAH were estimated at 16.5 million CHF, corresponding to a median cost of 4936 [4445-4961] Swiss Francs per stay. We conclude that in Switzerland, PAH have increased, represent a considerable fraction of hospitalizations for hypertension, and carry a non-negligible health cost.

Potentially avoidable hospitalizations and socioeconomic status in Switzerland: A small area-level analysis

The Swiss healthcare system is well known for the quality of its healthcare and population health but also for its high cost, particularly regarding out-of-pocket expenses. We conduct the first national study on the association between socioeconomic status and access to community-based ambulatory care (CBAC). We analyze administrative and hospital discharge data at the small area level over a four-year time period (2014 - 2017). We develop a socioeconomic deprivation indicator and rely on a well-accepted indicator of potentially avoidable hospitalizations as a measure of access to CBAC. We estimate socioeconomic gradients at the national and cantonal levels with mixed effects models pooled over four years. We compare gradient estimates among specifications without control variables and those that include control variables for area geography and physician availability. We find that the most deprived area is associated with an excess of 2.80 potentially avoidable hospitalizations per 1,000 population (3.01 with control variables) compared to the least deprived area. We also find significant gradient variation across cantons with a difference of 5.40 (5.54 with control variables) between the smallest and largest canton gradients. Addressing broader social determinants of health, financial barriers to access, and strengthening CBAC services in targeted areas would likely reduce the observed gap.

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

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.

Mapping Health Disparities in 11 High-Income Nations

Importance

Health care delivery faces a myriad of challenges globally with well-documented health inequities based on geographic location. Yet, researchers and policy makers have a limited understanding of the frequency of geographic health disparities.

Objective

To describe geographic health disparities in 11 high-income countries.

Design, Setting, and Participants

In this survey study, we analyzed results from the 2020 Commonwealth Fund International Health Policy (IHP) Survey-a nationally representative, self-reported, and cross-sectional survey of adults from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK, and the US. Eligible adults older than age 18 years were included by random sampling. Survey data were compared for the association of area type (rural or urban) with 10 health indicators across 3 domains: health status and socioeconomic risk factors, affordability of care, and access to care. Logistic regression was used to determine the associations between countries with area type for each factor, controlling for individuals' age and sex.

Main Outcomes and Measures

The main outcomes were geographic health disparities as measured by differences in respondents living in urban and rural settings in 10 health indicators across 3 domains.

Results

There were 22 402 survey respondents (12 804 female [57.2%]), with a 14% to 49% response rate depending on the country. Across the 11 countries and 10 health indicators and 3 domains (health status and socioeconomic risk factors, affordability of care, access to care), there were 21 occurrences of geographic health disparities; 13 of those in which rural residence was a protective factor and 8 of those where rural residence was a risk factor. The mean (SD) number of geographic health disparities in the countries was 1.9 (1.7). The US had statistically significant geographic health disparities in 5 of 10 indicators, the most of any country, while Canada, Norway, and the Netherlands had no statistically significant geographic health disparities. The indicators with the most occurrences of geographic health disparities were in the access to care domain.

Conclusions and Relevance

In this survey study of 11 high-income nations, health disparities across 10 indicators were identified. Differences in number of disparities reported by country suggest that health policy and decision makers in the US should look to Canada, Norway, and the Netherlands to improve geographic-based health equity.

Potentially Avoidable Hospitalizations by Asthma and COPD in Switzerland from 1998 to 2018: A Cross-Sectional Study

Potentially avoidable hospitalizations (PAH) are commonly used as an indicator for healthcare quality and primary care performance. However, data are usually presented in a restricted timeframe and for a specific region, limiting the identification of trends and national patterns. We aimed in this study to calculate rates, identify clinical determinants, and estimate costs of PAH for two frequent lung diseases (asthma and COPD) in Switzerland between 1998 and 2018 using hospital discharge data available for patients aged ≥20 years. PAH were defined according to the Health Care Quality Indicators Project (HCQIP) from the Organisation for Economic Co-operation and Development (OECD). The distribution of PAH in seven administrative regions (Leman, Mittelland, Northwest, Zurich, Eastern, Central, and Ticino) was calculated, along with PAH-associated total hospital days and Diagnosis-Related Group (DRG) estimated costs. Totals of 25,260 PAH for asthma and 135,069 PAH for COPD were identified in the 20-year period. The standardized rates of PAH per 100,000 people for asthma fluctuated from 18.7 in 1998 to 22.5 on 2018. The standardized rates of PAH per 100,000 people from COPD almost doubled from 77.4 in 1998 to 142.7 in 2018. In 2018, the estimated total costs of PAH amounted to 7.7 million CHF for asthma and 91.2 million CHF for COPD. We conclude that PAH for asthma and COPD represent a significant and unnecessary burden and costs of hospitalizations in Switzerland.

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

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

Using Ambulatory Care Sensitive Conditions to Assess Primary Health Care Performance during Disasters: A Systematic Review

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.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Hospitalization for ambulatory care sensitive conditions: What conditions make inter-country comparisons possible?

Hospitalizations for ambulatory care sensitive conditions have been extensively used in health services research to assess access, quality and performance of primary health care. Inter-country comparisons can assist policy-makers in pursuing better health outcomes by contrasting policy design, implementation and evaluation. The objective of this study is to identify the conceptual, methodological, contextual and policy dimensions and factors that need to be accounted for when comparing these types of hospitalizations across countries. A conceptual framework for inter-country comparisons was drawn based on a review of 18 studies with inter-country comparison of ambulatory care sensitive conditions hospitalizations. The dimensions include methodological choices; population's demographic, epidemiologic and socio-economic profiles and features of the health services and system. Main factors include access and quality of primary health care, availability of health workforce and health facilities, health interventions and inequalities. The proposed framework can assist in designing studies and interpreting findings of inter-country comparisons of ambulatory care sensitive conditions hospitalizations, accelerating learning and progress towards universal health coverage.

Emergency hospital admissions among older adults living alone in the community

Background

Among older adults, living alone is often associated with higher risk of Emergency Department (ED) admissions. However, older adults living alone are very heterogeneous in terms of health. As more older adults choose to live independently, it remains unclear if the association between living alone and ED admissions is moderated by health status. We studied the association between living alone and ED admission outcomes (number of admissions, inpatient days and inpatient costs) among older adults with and without multimorbidity.

Methods

We used data from 16,785 individuals of the third follow-up of the Singapore Chinese Health Study, a population-based cohort of older Singapore Chinese (mean age: 73(61-96) years). Participants were interviewed face-to-face from 2014 to 2016 for sociodemographic/health factors and followed-up for one year on ED admission outcomes using Singapore Ministry of Health’s Mediclaim Database. We first applied multivariable logistic regression and two-part models to test if living alone is a risk factor for ED admission outcomes. We then ran stratified and joint effect analysis to examine if the associations between living alone and ED admission outcomes were moderated by multimorbidity.

Results

Compared to living with others, living alone was associated with higher odds of ED admission [Odds Ratio (OR) 1.28, 95 % Confidence Interval(CI) 1.08-1.51)], longer inpatient days (+0.61, 95 %CI 0.25-0.97) and higher inpatient costs (+322 USD, 95 %CI 54-591). The interaction effects of living arrangement and multimorbidity on ED admissions and inpatient costs were not statistically different, whereas the interaction between living arrangements and multimorbidity on inpatient days was borderline significant (p-value for interaction=0.050). Compared to those living with others and without multimorbidity, the relative mean increase was 1.13 inpatient days (95 %CI 0.39-1.86) for those living alone without multimorbidity, and 0.73 inpatient days ( 95 %CI 0.29-1.17) for those living alone with multimorbidity.

Conclusions

Older adults living alone were at higher risk of ED admission and higher inpatient costs regardless of multimorbidity, while those living alone without multimorbidity had the longest average inpatient days. To enable aging in place while avoiding ED admissions, interventions could provide instrumental support and regular health monitoring to older adults living alone, regardless of their health status.

Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study

Background

Primary health care is subject to regional variation, which may be due to unequal and inefficient distribution of services. One key measure of such variation are potentially avoidable hospitalisations, i.e., hospitalisations for conditions that could have been dealt with in situ by sufficient primary health care provision. Particularly, potentially avoidable hospitalisations for ambulatory care-sensitive conditions (ACSCs) are a substantial and growing burden for health care systems that require targeting in health care policy.

Aims

Using data from the Swiss Federal Statistical Office (SFSO) from 2017, we applied small area analysis to visualize regional variation to comprehensively map potentially avoidable hospitalisations for five ACSCs from Swiss nursing homes, home care organisations and the general population.

Methods

This retrospective observational study used data on all Swiss hospitalisations in 2017 to assess regional variations of potentially avoidable hospitalisations for angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications and hypertension. We used small areas, utilisation-based hospital service areas (HSAs), and administrative districts (Cantons) as geographic zones. The outcomes of interest were age and sex standardised rates of potentially avoidable hospitalisations for ACSCs in adults (> 15 years). Our inferential analyses used linear mixed models with Gaussian distribution.

Results

We identified 46,479 hospitalisations for ACSC, or 4.3% of all hospitalisations. Most of these occurred in the elderly population for congestive heart failure and COPD. The median rate of potentially avoidable hospitalisation for ACSC was 527 (IQR 432–620) per 100.000 inhabitants. We found substantial regional variation for HSAs and administrative districts as well as disease-specific regional patterns.

Conclusions

Differences in continuity of care might be key drivers for regional variation of potentially avoidable hospitalisations for ACSCs. These results provide a new perspective on the functioning of primary care structures in Switzerland and call for novel approaches in effective primary care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06876-5.

Economic and financial crisis based on Troika's intervention and potentially avoidable hospitalizations: an ecological study in Portugal

BACKGROUND

Hospitalisations for Ambulatory Care Sensitive Conditions (ACSC) cause harm to users and to health systems, as these events are potentially avoidable. In 2009, Portugal was hit by an economic and financial crisis and in 2011 it resorted to foreign assistance ("Memorandum of Understanding" (2011-2014)). The aim of this study was to analyse the association between the Troika intervention and hospitalisations for ACSC.

METHODS

We analysed inpatient data of all public NHS hospitals of mainland Portugal from 2007 to 2016, and identified hospitalisations for ACSC (pneumonia, chronic obstructive pulmonary disease, hearth failure, hypertensive heart disease, urinary tract infections, diabetes), according to the AHRQ methodology. Rates of hospitalisations for ACSC, the rate of enrollment in the employment center and average monthly earnings were compared among the pre-crisis, crisis and post-crisis periods to see if there were differences. A Spearman's correlation between socioeconomic variables and hospitalisations was performed.

RESULTS

Among 8,160,762 admissions, 892,759 (10.94%) were classified as ACSC hospitalizations, for which 40% corresponded to pneumonia. The rates of total hospitalisations and hospitalisations for ACSC increased between 2007 and 2016, with the central and northern regions of the country presenting the highest rates. No correlations between socioeconomic variables and hospitalisation rates were found.

CONCLUSIONS

During the period of economic and financial crisis based on Troika's intervention, there was an increase in potentially preventable hospitalisations in Portugal, with disparities between the municipalities. The high use of resources from ACSC hospitalisations and the consequences of the measures taken during the crisis are factors that health management must take into account.

Individual and Area-level Factors Contributing to the Geographic Variation in Ambulatory Care Sensitive Conditions in Finland: A Register-based Study

BACKGROUND

Measuring primary health care (PHC) performance through hospitalizations for ambulatory care sensitive conditions (ACSCs) remains controversial-recent cross-sectional research claims that its geographic variation associates more with individual socioeconomic position (SEP) and health status than PHC supply.

OBJECTIVES

To clarify the usage of ACSCs as a PHC performance indicator by quantifying how disease burden, both PHC and hospital supply and spatial access contribute over time to geographic variation in Finland when individual SEP and comorbidities were adjusted for.

METHODS

The Finnish Care Register for Health Care provided hospitalizations for ACSCs (divided further into subgroups of acute, chronic, and vaccine-preventable causes) in 2011-2017. With 3-level nested multilevel Poisson models-individuals, PHC authorities, and hospital authorities-we estimated the proportion of the variance in ACSCs explained by selected factors at 3 time periods.

RESULTS

In age-adjusted and sex-adjusted analysis of total ACSCs the variances between hospital authorities was nearly twice that between PHC authorities. Individual SEP and comorbidities explained 19%-30% of the variance between PHC authorities and 25%-36% between hospital authorities; and area-level disease burden and arrangement and usage of hospital care a further 14%-16% and 32%-33%-evening out the unexplained variances between PHC and hospital authorities.

CONCLUSIONS

Alongside individual factors, areas' disease burden and factors related to hospital care explained the excess variances in ACSCs captured by hospital authorities. Our consistent findings over time suggest that the local strain on health care and the regional arrangement of hospital services affect ACSCs-necessitating caution when comparing areas' PHC performance through ACSCs.

Regional Characteristics of Hospital Admissions and Outpatients Visits with Arterial Hypertension from the Point of the WHO Concept of Ambulatory Care Sensitive Conditions

Aim. To analyze hospital admission and ambulatory care of the patients with arterial hypertension (AH) in federal districts and regions from the perspective of the WHO concept of diseases, which can be treated in ambulatory settings (ambulatory care sensitive conditions, ACSC).Material and methods. For analysis we used data from annual forms of federal statistical monitoring (12 and 14), which includes data on hospital admissions with hypertension in federal districts and separate regions in 2017. Hypertension included diseases characterized by raised blood pressure, ICD10: I10-I13.Results. We performed the analysis of 12 and 14 forms per districts and regions of the Russian Federation. Regions with increased hospitalization rates and an increased ratio of the hospitalizations to number to outpatients visits were identified. High variability of these indicators was observed both among both between regions and federal districts. The values of the ratio indicator vary from 0.0131 in the Nizhny Novgorod Region to 0.0234 in the Chechen Republic. The average value of the ratio in the federal district varies from 0.032 in the Volga Federal District to 0.119 in the North Caucasus Federal District. In the North Caucasus and Far East Federal District the value of the indicator is significantly higher than in other districts.

Conclusion. Assessing diseases which can be treated in ambulatory setting scan be one of the tools for evaluating the quality of medical care in primary care facilities. However, before including ACSC as an indicator of the quality of health care delivery, a deeper understanding of the reasons that can impact its rates is required.

Defining ambulatory care sensitive conditions for adults in Portugal

BACKGROUND

Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal.

METHODS

A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions.

RESULTS

After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus.

CONCLUSIONS

New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms

Policies aiming to spur quality competition among health care providers are ubiquitous, but their impact on quality is ex ante ambiguous, and credible empirical evidence is lacking in many contexts. This study contributes to the sparse literature on competition and primary care quality by examining recent competition enhancing reforms in Sweden. The reforms aimed to stimulate patient choice and entry of private providers across the country but affected markets differently depending on the initial market structure. We exploit the heterogeneous impact of the reforms in a difference-in-differences strategy, contrasting more and less exposed markets over the period 2005-2013. Although the reforms led to substantially more entry of new providers in more exposed markets, the effects on primary care quality were modest: We find small improvements of patients' overall satisfaction with care, but no consistently significant effects on avoidable hospitalisation rates or satisfaction with access to care. We find no evidence of economically meaningful quality reductions on any outcome measure.

Geographic variation in preventable hospitalisations across Canada: a cross-sectional study

OBJECTIVE

The objective of this study is to examine the magnitude and pattern of small-area geographic variation in rates of preventable hospitalisations for ambulatory care-sensitive conditions (ACSC) across Canada (excluding Québec).

DESIGN AND SETTING

A cross-sectional study conducted in Canada (excluding Québec) using data from the 2006 Canadian Census Health and Environment Cohort (CanCHEC) linked prospectively to hospitalisation records from the Discharge Abstract Database (DAD) for the three fiscal years: 2006-2007, 2007-2008 and 2008-2009.

PRIMARY OUTCOME MEASURE

Preventable hospitalisations (ACSC).

PARTICIPANTS

The 2006 CanCHEC represents a population of 22 562 120 individuals in Canada (excluding Québec). Of this number, 2 940 150 (13.03%) individuals were estimated to be hospitalised at least once during the 2006-2009 fiscal years.

METHODS

Age-standardised annualised ACSC hospitalisation rates per 100 000 population were computed for each of the 190 Census Divisions. To assess the magnitude of Census Division-level geographic variation in rates of preventable hospitalisations, the global Moran's I statistic was computed. 'Hot spot' analysis was used to identify the pattern of geographic variation.

RESULTS

Of all the hospitalisation events reported in Canada during the 2006-2009 fiscal years, 337 995 (7.10%) events were ACSC-related hospitalisations. The Moran's I statistic (Moran's I=0.355) suggests non-randomness in the spatial distribution of preventable hospitalisations. The findings from the 'hot spot' analysis indicate a cluster of Census Divisions located in predominantly rural and remote parts of Ontario, Manitoba and Saskatchewan and in eastern and northern parts of Nunavut with significantly higher than average rates of preventable hospitalisation.

CONCLUSION

The knowledge generated on the small-area geographic variation in preventable hospitalisations can inform regional, provincial and national decision makers on planning, allocation of resources and monitoring performance of health service providers.

Inefficiencies in a healthcare system with a regulatory split of power: a spatial panel data analysis of avoidable hospitalisations in Austria

Despite generous universal social health insurance with little formal restrictions of outpatient utilisation, Austria exhibits high rates of avoidable hospitalisations, which indicate the inefficient provision of primary healthcare and might be a consequence of the strict regulatory split between the Austrian inpatient and outpatient sector. This paper exploits the considerable regional variations in acute and chronic avoidable hospitalisations in Austria to investigate whether those inefficiencies in primary care are rather related to regional healthcare supply or to population characteristics. To explicitly account for inter-regional dependencies, spatial panel data methods are applied to a comprehensive administrative dataset of all hospitalisations from 2008 to 2013 in the 117 Austrian districts. The initial selection of relevant covariates is based on Bayesian model averaging. The results of the analysis show that supply-side variables, such as the number of general practitioners, are significantly associated with decreased chronic and acute avoidable hospitalisations, whereas characteristics of the regional population, such as the share of population with university education or long-term unemployed, are less relevant. Furthermore, the spatial error term indicates that there are significant spatial dependencies between unobserved characteristics, such as practice style or patients' utilization behaviour. Not accounting for those would result in omitted variable bias.

Prospectively identifying older adults at risk for potentially avoidable hospitalizations in Korea using population-based data

OBJECTIVE

The purpose of this study is to develop and validate a prediction model to identify older adults at risk for potentially avoidable hospitalizations (PAHs) using variables readily available in routinely collected health administrative data.

DESIGN

Population-based, retrospective observational study using National Health Insurance Service-National Sample Cohort (NHIS-NSC) data.

SETTING

Primary care settings in South Korea.

PARTICIPANTS

The sample includes 113 612 older NHI beneficiaries in the year 2011, among which 2856 had one or more PAHs in 2012.

METHODS

We examined multi-dimensional risk factors of PAHs in the base year and developed and validated prediction models of hospitalization risk using the following year. The predictive power of the developed models was examined with samples generated by the bootstrap method. The performance of the final model was evaluated with further test statistics at different risk thresholds.

MAIN OUTCOME MEASURE

Predicting PAHs.

RESULTS

The c-statistic of the final predictive model was 0.784 (CI: 0.769-0.799). The final model including all selected predictors showed the greatest marginal improvement (integrated discrimination improvement of 365%) compared to the base model. The positive predictive value was good.

CONCLUSIONS

Our prediction model based on health administrative data can assist the insurer and practitioners to proactively identify and intervene with older adults at risk for a PAH.

Predictors of hospitalizations for diabetes in Germany: an ecological study on a small-area scale

OBJECTIVES

Our objective was to evaluate the role of potential predictors in explaining spatial variation among diabetes hospitalization rates in Germany.

STUDY DESIGN

This was an ecological analysis using hospital routine data.

METHODS

County-level hospitalization rates (n = 402) in 2015 were calculated based on the German Diagnosis Related Groups database. We used a funnel plot to identify counties with high hospitalization rates. To examine the impact of predictors such as socio-economic status or structure of primary care, we performed linear and logistic regression analyses.

RESULTS

The crude hospitalization rate was 262 admissions per 100,000 population. In multivariable logistic models, we found the percentage of employees with academic degree (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.56-0.91), high hospital bed rate (4th quartile vs 1st quartile; OR: 2.73, CI: 1.03-7.24), and diabetes prevalence (OR: 1.49, CI: 1.17-1.90) to be significant predictors for high hospitalization rates. In multivariable linear models, the percentage of unemployed (regression coefficient b: 4.79, CI: 0.81-8.78) and rurality (b: 0.52, CI: 0.19-0.85) explained the variation in addition to predictors from logistic regression. Primary care structure was not a significant predictor in multivariable models.

CONCLUSIONS

The non-significant impact of primary care in adjusted models casts the use of diabetes hospitalizations as indicators for access and quality of primary care into doubt. Diabetes hospitalizations may rather reflect demand for care.

Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland

OBJECTIVES

Reducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations.

METHODS

Using merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital.

RESULTS

Approximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013.

CONCLUSIONS

A sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.

Avoidable hospitalizations in Brazil and Portugal: Identifying and comparing critical areas through spatial analysis

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions have been used to assess the performance of primary health care. Few studies have compared geographic variation in rates of avoidable hospitalizations and characteristics of high-risk areas within and between countries. The aim of this study was to identify and compare critical areas of avoidable hospitalizations in Brazil and Portugal, because these countries have reformed their primary health care systems in recent years and have similar organizational characteristics.

METHODS

An ecological study on hospitalizations for ambulatory care sensitive conditions produced in Brazil and Portugal in 2015 was used. Geographic variation of rates were analyzed and compared at the municipal level. A spatial scan statistic was employed to identify clusters with higher risk of hospitalizations for acute and chronic conditions in each country separately. Socioeconomic and primary health care characteristics of critical areas were compared to non-critical areas.

RESULTS

There were high variations in rates of avoidable hospitalizations within and between Brazil and Portugal, with higher variations found in Brazil. A more evident pattern of rates was found in Portugal. Rates and cluster distribution of acute and chronic conditions had significant agreement for both countries. The differences in primary health care and socioeconomic characteristics between areas identified as high risk clusters and non-clusters varied between category of conditions and between countries.

CONCLUSION

Brazil and Portugal presented expressive regional differences with respect to rates of avoidable hospitalizations, indicating that there is room to improve by reducing such events in both countries. Different areas presented distinct interactions between primary health care, socioeconomic characteristics, and avoidable hospitalizations. Results indicate that the primary health care reforms, with similar organizational characteristics in different contexts, did not produce similar results either between or within countries. Possible actions to reduce these events should be defined at a local level.

Do hospitals influence geographic variation in admission for preventable hospitalisation? A data linkage study in New South Wales, Australia

OBJECTIVE

Preventable hospitalisations are used internationally as a performance indicator for primary care, but the influence of other health system factors remains poorly understood. This study investigated between-hospital variation in rates of preventable hospitalisation.

SETTING

Linked health survey and hospital admissions data for a cohort study of 266 826 people aged over 45 years in the state of New South Wales, Australia.

METHOD

Between-hospital variation in preventable hospitalisation was quantified using cross-classified multiple-membership multilevel Poisson models, adjusted for personal sociodemographic, health and area-level contextual characteristics. Variation was also explored for two conditions unlikely to be influenced by discretionary admission practice: emergency admissions for acute myocardial infarction (AMI) and hip fracture.

RESULTS

We found significant between-hospital variation in adjusted rates of preventable hospitalisation, with hospitals varying on average 26% from the state mean. Patients served more by community and multipurpose facilities (smaller facilities primarily in rural areas) had higher rates of preventable hospitalisation. Community hospitals had the greatest between-hospital variation, and included the facilities with the highest rates of preventable hospitalisation. There was comparatively little between-hospital variation in rates of admission for AMI and hip fracture.

CONCLUSIONS

Geographic variation in preventable hospitalisation is determined in part by hospitals, reflecting different roles played by community and multipurpose facilities, compared with major and principal referral hospitals, within the community. Care should be taken when interpreting the indicator simply as a performance measure for primary care.

Does rural health system reform aimed at improving access to primary health care affect hospitalization rates? An interrupted time series analysis of national policy reforms in Iran

OBJECTIVES

To evaluate the effects of rural health insurance and family physician reforms on hospitalization rates in Iran.

METHODS

An interrupted time series analysis of national monthly hospitalization rates in Iran (2003-2014), starting from two years before the intervention. Segmented regression analysis was used to assess the effects of the reforms on hospitalization rates.

RESULTS

The analyses showed that hospitalization rates increased one year after the initiation of the reforms: 1.55 (95% CI: 1.24-1.86) additional hospitalizations per 1000 rural inhabitants per month ('immediate effect'). This increase was followed by a further gradual increase of 0.034 per 1000 inhabitants per month (95% CI: 0.02-0.04). The gradual monthly increase continued for two years after the reforms. The higher hospitalization rates were maintained in the following years. We observed a significant increase in hospitalization rates at a national level in rural areas that continued for over 10 years after the policy implementation.

CONCLUSION

Primary health care reforms are often proposed for their efficiency outcomes (i.e. reduction in costs and use of hospitals) as well as their impact on improving health outcomes. We demonstrated that in populations with unmet needs, such reforms are likely to substantially increase hospitalization rates. This is an important consideration for successful design and implementation of interventions aimed at achieving universal health coverage in low- and middle-income countries.

Associations between structures and resources of primary care at the district level and health outcomes: a case study of diabetes mellitus care in Thailand

Background

The structural factors of primary care potentially influence its performance and quality. This study investigated the association between structural factors, including available primary care resources and health outcomes, by using diabetes-related ambulatory care sensitive conditions hospitalizations under the Universal Coverage Scheme in Thailand.

Methods

A 2-year panel study used secondary data compiled at the district level. Administrative claim data from 838 districts during the 2014–2015 fiscal years from the National Health Security Office were used to analyze overall diabetes mellitus (DM) hospitalizations and its three subgroups: hospitalizations for uncontrolled diabetes, short-term complications, and long-term complications. Primary care structural data were obtained from the Ministry of Public Health. Generalized estimating equations were used to estimate the influence of structural factors on the age-standardized DM hospitalization ratio.

Results

A higher overall DM and uncontrolled diabetes hospitalization ratio was related to an increasing concentration of outpatient utilization (using the Herfindahl–Hirschman Index) (overall DM; beta [standard error, SE]=0.003 [0.001], 95% CI 0.000, 0.006) and decreasing physician density and bed supply (overall DM; beta [SE]=−1.350 [0.674], 95% CI −2.671, −0.028), beta [SE]=−0.023 [0.011], 95% CI −0.045, −0.001, respectively). Hospitalizations for short-term complications increased with a decrease in health care facility density, whereas hospitalizations for long-term complications increased as that density increased. Rurality was strongly associated with higher hospitalization ratios for all DM hospitalizations except short-term complications.

Conclusions

This study identified structural factors associated with health outcomes, many of which can be changed through reorganization at the district level.

Access to healthcare for undocumented migrants: analysis of avoidable hospital admissions in Sicily from 2003 to 2013

Background

Access to healthcare services for undocumented migrants is one of the main public health issues currently being debated among European countries. Exclusion from primary healthcare services may lead to serious consequences for migrants' health. We analyzed the risk among undocumented migrants, in comparison with regular migrants, of being hospitalized for preventable conditions in the Region of Sicily (Italy). We performed a hospital-based cross-sectional study of the foreign population hospitalized in the Sicily region between 1 January 2003 and 31 December 2013. The first outcome was the proportion of avoidable hospitalization (AHs) among regular and irregular migrants. Second outcomes were the subcategories of AHs for chronic, acute and vaccine preventable diseases. 85 309 hospital admissions were analyzed. In the hospitalized population, in comparison to regular migrants, undocumented migrants show a higher proportion of hospitalization for diseases preventable through primary and preventive care (AOR1·48, 95%CI 1·37-1·59). The proportion of avoidable hospitalizations associated with the lack of legal status is higher for vaccine preventable conditions (AOR 2·06, 95%CI 1·66-2·56) than for chronic conditions (AOR 1·47, 95%CI 1·42-1·63) and acute conditions (AOR 1·37; 95%CI 1·23-1·53). Between 2003 and 2013, the proportion of avoidable hospitalizations decreased both in regular and undocumented migrants but decreased faster for regular than for undocumented migrants. Undocumented migrants experience higher proportion of hospitalization for preventable conditions in comparison with regular migrants probably due to a lack of access to the national healthcare service. Policies and strategies to involve them in primary healthcare and preventive services should be developed to tackle this inequality.

[Effect of the Family Health Strategy on hospitalizations for primary care sensitive conditions in infants in Bahia State, Brazil]

This study aimed to assess the effect of the expansion of the Family Health Strategy (FHS) on hospitalizations for primary care sensitive conditions (PCSCs) in children under one year of age. This was a longitudinal ecological study with the use of panel data, for which the analytical units were the 417 municipalities (counties) in Bahia State, Brazil, from 2000 to 2012. Data were obtained from the official health information systems. The hospitalization rate for PCSCs was the outcome and FHS coverage was the principal exposure. The co-variables referred to demographic and socioeconomic characteristics and the local availability of pediatric beds. Bivariate and multivariate panel data analyses were performed, with negative binomial response and fixed effects models, using crude and adjusted relative risk (RR) as the measure of association, with the respective confidence intervals. To control for trend effect, the models were adjusted for time. From 2000 to 2012, 248,944 hospitalizations for PCSCs were recorded in children under one year, and the median municipal rate of hospitalizations for PCSCs decreased by 52.5% during the period, ranging from 96.9 to 46.0 avoidable hospitalizations per 1,000 live births. After adjusting the model, the reduction in avoidable hospitalizations was maintained at the different FHS coverage levels. This study demonstrated the effects of the consolidation of the FHS on hospitalizations for PCSCs in infants, which indicates the importance of strengthening primary care measures in order to offer case-resolving care during the first contact with the health system and avoid unnecessary hospitalizations.

Using Weighted Hospital Service Area Networks to Explore Variation in Preventable Hospitalization

Objective

To demonstrate the use of multiple‐membership multilevel models, which analytically structure patients in a weighted network of hospitals, for exploring between‐hospital variation in preventable hospitalizations.

Data Sources

Cohort of 267,014 people aged over 45 in NSW, Australia.

Study Design

Patterns of patient flow were used to create weighted hospital service area networks (weighted‐HSANs) to 79 large public hospitals of admission. Multiple‐membership multilevel models on rates of preventable hospitalization, modeling participants structured within weighted‐HSANs, were contrasted with models clustering on 72 hospital service areas (HSAs) that assigned participants to a discrete geographic region.

Data Collection/Extraction Methods

Linked survey and hospital admission data.

Principal Findings

Between‐hospital variation in rates of preventable hospitalization was more than two times greater when modeled using weighted‐HSANs rather than HSAs. Use of weighted‐HSANs permitted identification of small hospitals with particularly high rates of admission and influenced performance ranking of hospitals, particularly those with a broadly distributed patient base. There was no significant association with hospital bed occupancy.

Conclusion

Multiple‐membership multilevel models can analytically capture information lost on patient attribution when creating discrete health care catchments. Weighted‐HSANs have broad potential application in health services research and can be used across methods for creating patient catchments.

Factors associated with hospitalisations in chronic conditions deemed avoidable: ecological study in the Spanish healthcare system

OBJECTIVES

Potentially avoidable hospitalisations have been used as a proxy for primary care quality. We aimed to analyse the ecological association between contextual and systemic factors featured in the Spanish healthcare system and the variation in potentially avoidable hospitalisations for a number of chronic conditions.

METHODS

A cross-section ecological study based on the linkage of administrative data sources from virtually all healthcare areas (n=202) and autonomous communities (n=16) composing the Spanish National Health System was performed. Potentially avoidable hospitalisations in chronic conditions were defined using the Spanish validation of the Agency for Health Research and Quality (AHRQ) preventable quality indicators. Using 2012 data, the ecological association between potentially avoidable hospitalisations and factors featuring healthcare areas and autonomous communities was tested using multilevel negative binomial regression.

RESULTS

In 2012, 151 468 admissions were flagged as potentially avoidable in Spain. After adjusting for differences in age, sex and burden of disease, the only variable associated with the outcome was hospitalisation intensity for any cause in previous years (incidence risk ratio 1.19 (95% CI 1.13 to 1.26)). The autonomous community of residence explained a negligible part of the residual unexplained variation (variance 0.01 (SE 0.008)). Primary care supply and activity did not show any association.

CONCLUSIONS

The findings suggest that the variation in potentially avoidable hospitalisations in chronic conditions at the healthcare area level is a reflection of how intensively hospitals are used in a healthcare area for any cause, rather than of primary care characteristics. Whether other non-studied features at the healthcare area level or primary care level could explain the observed variation remains uncertain.

Regional differences in mortality, hospital discharges and primary care contacts for cardiovascular disease

Aims: Surveillance of geographical variations in cardiovascular health is important in order to achieve the objectives of reducing regional health disparities. We aimed to explore differences in cardiovascular disease (CVD) mortality and prevalence of CVD diagnoses made in primary and in-patient care, as well as risk factor distribution by geographic regions (urban/rural) in Iceland. Methods: From nationwide health registers, we obtained data on CVD mortalities ( N = 7113), primary healthcare CVD contacts ( N = 58,246) and hospital CVD discharges ( N = 14,039), as well as data on CVD risk factors from a national health survey ( N = 5909; response rate 60.3%). Age-standardised annual mortality, primary healthcare contact and hospital discharge rates due to CVD were calculated per 100,000 population inside (urban) and outside (rural) the Capital Area (CA). Logistic regression was used to explore regional differences in CVD risk factors. Results: We observed slightly higher total CVD mortality rates among women outside compared to inside the CA (Standardised Rate Ratio (SRR) 1.06 (95% confidence interval (CI) 1.05–1.07)), particularly due to atrial fibrillation (SRR 1.47 (95% CI 1.46–1.48)), heart failure (SRR 1.29 (95% CI 1.27–1.31)) and ischemic heart disease (SRR 1.11 (95% CI 1.10–1.12)), while reduced mortality risk for cerebrovascular disease (SRR 0.81 (95% CI 0.80–0.83)). The rates of hospital discharges and primary care contacts for these diseases, as well as prevalence of several modifiable risk factors, were generally higher outside the CA, particularly among women. Conclusions:The higher prevalence of modifiable risk factors and CVD in rural areas, especially among women, calls for refined treatment and health-promoting efforts in rural areas.

[Routine Data in Health Services Research: an Underused Resource]

Zusammenfassung. Routinedaten entstehen als Nebenprodukt des normalen Betriebsalltags. Diese ohne Zusatzaufwand massenhaft generierten Daten lassen sich mit ökonomischen oder im Falle der Medizin auch mit gesundheitlichen Fragestellungen auswerten. Durch die nicht-kontrollierte Art der Sammlung von Routinedaten sowie aufgrund der uneinheitlichen Handhabung von elektronischen Krankengeschichten ergeben sich aber je nach Fragestellung Grenzen der Aussagekraft von Resultaten. Dieser Artikel widmet sich den Fragen rund um Herkunft, Verarbeitung, Interpretation und Nutzen von Routinedaten. Dabei werden auch Machine Learning und Big Data kritisch in den Kontext gebracht, sowie die Aspekte Datenschutz und Ethik. Hinsichtlich des Schweizer Gesundheitssystems zeigt der Artikel die notwendigen Voraussetzungen, damit das Potential von Routinedaten auch hierzulande zugunsten einer besseren medizinischen Versorgung genutzt werden kann.

Potentially avoidable and ambulatory care sensitive hospitalisations among forced migrants: a protocol for a systematic review and meta-analysis

INTRODUCTION

There is an increasing number of forced migrants globally, including refugees, asylum seekers, internally displaced persons and undocumented migrants. According to international law, forced migrants should enjoy access to health services free of discrimination equivalent to the host population, but they face barriers to healthcare worldwide. This may lead to a delay in care and result in preventable hospital treatment, referred to as potentially preventable hospitalisation (PPH) or ambulatory care sensitive hospitalisation (ACSH). There is as yet no overview of the prevalence of PPH in different countries and groups of forced migrants, and it is unknown whether the concept has been used among these migrant groups. We aim to systematically review the evidence (1) on the prevalence of PPH among forced migrants and (2) on differences in the prevalence of PPH between forced migrants and the general host population.

METHODS AND ANALYSIS

A systematic review will be conducted searching databases (PubMed/MEDLINE, Web of Science/Knowledge, Cochrane Library, CINAHL, Google Scholar) and the internet (Google).

INCLUSION CRITERIA

observational studies on forced migrants reporting PPH or ACSH with or without comparison groups published in the English or German language.

EXCLUSION CRITERIA

studies on general migrant groups or hospitalisations without clear reference to avoidability.

STUDY SELECTION

titles, abstracts and full texts will be screened in duplicate for eligibility. Data on the prevalence of PPH/ACSH among forced migrants, as well as any reported prevalence differences between host populations, will be systematically extracted. Quality appraisal will be performed using standardised checklists. The evidence will be synthesised in tabular form and by means of forest plots. A meta-analysis will be performed only among homogeneous studies (in terms of design and population).

ETHICS AND DISSEMINATION

Ethical clearance is not necessary (secondary research). The results will be disseminated via publication in open access journals, conferences and public media.

PROSPERO REGISTRATION NUMBER

CRD42016037081.

Visualising linked health data to explore health events around preventable hospitalisations in NSW Australia

OBJECTIVE

To explore patterns of health service use in the lead-up to, and following, admission for a 'preventable' hospitalisation.

SETTING

266 950 participants in the 45 and Up Study, New South Wales (NSW) Australia

METHODS

Linked data on hospital admissions, general practitioner (GP) visits and other health events were used to create visual representations of health service use. For each participant, health events were plotted against time, with different events juxtaposed using different markers and panels of data. Various visualisations were explored by patient characteristics, and compared with a cohort of non-admitted participants matched on sociodemographic and health characteristics. Health events were displayed over calendar year and in the 90 days surrounding first preventable hospitalisation.

RESULTS

The visualisations revealed patterns of clustering of GP consultations in the lead-up to, and following, preventable hospitalisation, with 14% of patients having a consultation on the day of admission and 27% in the prior week. There was a clustering of deaths and other hospitalisations following discharge, particularly for patients with a long length of stay, suggesting patients may have been in a state of health deterioration. Specialist consultations were primarily clustered during the period of hospitalisation. Rates of all health events were higher in patients admitted for a preventable hospitalisation than the matched non-admitted cohort.

CONCLUSIONS

We did not find evidence of limited use of primary care services in the lead-up to a preventable hospitalisation, rather people with preventable hospitalisations tended to have high levels of engagement with multiple elements of the healthcare system. As such, preventable hospitalisations might be better used as a tool for identifying sicker patients for managed care programmes. Visualising longitudinal health data was found to be a powerful strategy for uncovering patterns of health service use, and such visualisations have potential to be more widely adopted in health services research.

Health Care Utilisation and Transitions between Health Care Settings in the Last 6 Months of Life in Switzerland

BACKGROUND

Many efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society.

AIM

We aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population.

METHODS

The study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions.

RESULTS

Mean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions.

CONCLUSIONS

Health care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions.

Prostate cancer screening in Switzerland: 20-year trends and socioeconomic disparities

BACKGROUND

Despite important controversy in its efficacy, prostate cancer (PCa) screening has become widespread. Important socioeconomic screening disparities have been reported. However, trends in PCa screening and social disparities have not been investigated in Switzerland, a high risk country for PCa. We used data from five waves (from 1992-2012) of the population-based Swiss Health Interview Survey to evaluate trends in PCa screening and its association with socioeconomic indicators.

METHODS

We used multivariable Poisson regression to estimate prevalence ratios (PR) and 95% Confidence Intervals (CI) adjusting for demographics, health status, and use of healthcare.

RESULTS

The study included 12,034 men aged ≥50 years (mean age: 63.9). Between 1992 and 2012, ever use of PCa screening increased from 55.3% to 70.0% and its use within the last two years from 32.6% to 42.4% (p-value <0.05). Income, education, and occupational class were independently associated with PCa screening. PCa screening within the last two years was greater in men with the highest (>$6,000/month) vs. lowest income (≤$2,000) (46.5% vs. 38.7% in 2012, PR for overall period =1.29, 95%CI: 1.13-1.48). These socioeconomic disparities did not significantly change over time.

CONCLUSIONS

This study shows that about half of Swiss men had performed at least one PCa screening. Men belonging to high socioeconomic status are clearly more frequently screened than those less favored. Given the uncertainty of the usefulness of PCa screening, men, including those with high socioeconomic status, should be clearly informed about benefits and harms of PCa screening, in particular, the adverse effect of over-diagnosis and of associated over-treatment.

Rising prevalence of back pain in Austria: considering regional disparities

BACKGROUND

Back pain is the most common form of musculoskeletal conditions and leads to high health care costs. Information about geographic variations in highly prevalent diseases/disorders represents important implications for public health planning to face structural challenges. The present study aims to investigate regional trends in the prevalence of back pain and the role of obesity and social inequalities among Austrian adults.

METHODS

A secondary data analysis based on five nationally representative cross-sectional surveys (1973-2007) was carried out (N = 178,818). Back pain was measured as self-reported presence. Obesity (BMI ≥ 30 kg/m²) was adjusted for self-report bias. For the regional analyses, Austria was divided into Western, Central and Eastern Austria. A relative index of inequality (RII) was computed to quantify the extent of social inequality.

RESULTS

A continuous rise in back pain prevalence was observed in the three regions and among all investigated subgroups. In 2007 the age-standardised prevalence was similar in Central (36.9 %), Western (35.2 %) and Eastern Austria (34.3 %). The absolute change in back pain prevalence was highest among obese subjects in Central Austria (women: + 29.8 %, men: + 32.5 %). RIIs were unstable during the study period and in 2007 highest in Eastern Austria.

CONCLUSION

Variation and trends in back pain are not attributable to geographic variation in Austria: an assumed East-West gradient in Austria has not been confirmed. Nevertheless our study confirms that back pain dramatically increased in all Austrian regions and investigated subgroups. This worrying trend should be further monitored and public health interventions should be implemented increasingly, especially among obese women and men.

Which hospitalisations are ambulatory care-sensitive, to what degree, and how could the rates be reduced? Results of a group consensus study in Germany

BACKGROUND

Much has been written lately regarding hospitalisations for ambulatory care-sensitive conditions (ACSH) and their strengths and weaknesses as a quality management indicator. The idea underlying ambulatory care-sensitive conditions (ACSC) is that effective treatment of acute conditions, good management of chronic illnesses and immunisation against infectious diseases can reduce the risk of a specified set of hospitalisations.

METHODS

The present paper applies group consensus methods to synthesise available evidence with expert opinion, thus identifying relevant ACSC. It contributes to the literature by evaluating the degree of preventability of ACSH and surveying the medical and systemic changes needed to increase quality for each diagnosis group. Forty physicians proportionally selected from all medical disciplines relevant to the treatment of ACSC participated in the three round Delphi survey. The setting of the study is Germany.

RESULTS

The proposed core list is a subset of 22 ACSC diagnosis groups, covering 90% of all consented ACSH and conditions with a higher than 85% estimated degree of preventability. Of all 18.6 million German hospital cases in the year 2012, the panelists considered 5.04 million hospitalisations (27%) to be sensitive to ambulatory care, of which 3.72 (20%) were estimated to be actually preventable. If only emergencies are considered, the ACSH share reduces to less than 8%. The geographic distribution of ACSH indicates significant regional variation with particularly high rates and potential for improvement in the North Rhine region, in Thuringia, Saxony-Anhalt, northern and eastern Bavaria and the Saarland. The average degree of preventability was 75% across all diagnosis groups. By far the most often mentioned strategy for reducing ACSH was 'improving continuous care'.

CONCLUSION

There are several good reasons why process indicators prevail in the assessment of ambulatory care. ACSH rates can however provide a more complete picture by adding useful information related to the overall patient outcome. The results of our analysis should be used to encourage debate and as a basis for further confirmatory work.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia

Supplemental Digital Content is available in the text.

Background:

Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions.

Objective:

To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization.

Methods:

Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization.

Results:

GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%).

Conclusions:

Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.