The devil is in the details: trends in avoidable hospitalization rates by geography in British Columbia, 1990-2000

A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT)

INTRODUCTION

Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data.

METHODS AND ANALYSIS

The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement.

ETHICS AND DISSEMINATION

This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.

Risk Factors Associated with Preventable Hospitalisation among Rural Community-Dwelling Patients: A Systematic Review

Potentially preventable hospitalisations (PPHs) are common and increase the burden on already stretched healthcare services. Increasingly, psychosocial factors have been recognised as contributing to PPHs and these may be mitigated through greater attention to social capital. This systematic review investigates the factors associated with PPHs within rural populations. The review was designed, conducted, and reported according to PRISMA guidelines and registered with Prospero (ID: CRD42020152194). Four databases were systematically searched, and all potentially relevant papers were screened at the title/abstract level, followed by full-text review by at least two reviewers. Papers published between 2000-2022 were included. Quality assessment was conducted using Newcastle-Ottawa Scale and CASP Qualitative checklist. Of the thirteen papers included, eight were quantitative/descriptive and five were qualitative studies. All were from either Australia or the USA. Access to primary healthcare was frequently identified as a determinant of PPH. Socioeconomic, psychosocial, and geographical factors were commonly identified in the qualitative studies. This systematic review highlights the inherent attributes of rural populations that predispose them to PPHs. Equal importance should be given to supply/system factors that restrict access and patient-level factors that influence the ability and capacity of rural communities to receive appropriate primary healthcare.

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.

Exploration of Preventable Hospitalizations for Colorectal Cancer with the National Cancer Control Program in Taiwan

Background: Causing more than 40,000 deaths each year, cancer is one of the leading causes of mortality and preventable hospitalizations (PH) in Taiwan. To reduce the incidence and severity of cancer, the National Cancer Control Program (NCCP) includes screening for various types of cancer. A cohort study was conducted to explore the long-term trends in PH/person-years following NCCP intervention from 1997 to 2013. Methods: Trend analysis was carried out for long-term hospitalization. The Poisson regression model was used to compare PH/person-years before (1997–2004) and after intervention (2005–2013), and to explore the impact of policy intervention. Results: The policy response reduced 26% for the risk of hospitalization; in terms of comorbidity, each additional point increased the risk of hospitalization by 2.15 times. The risk of hospitalization doubled for each 10-year increase but was not statistically significant. Trend analysis validates changes in the number of hospitalizations/person-years in 2005. Conclusions: PH is adopted as an indicator for monitoring primary care quality, providing governments with a useful reference for which to gauge the adequacy, accessibility, and quality of health care. Differences in PH rates between rural and urban areas can also be used as a reference for achieving equitable distribution of medical resources.

The rural tax: comprehensive out-of-pocket costs associated with patient travel in British Columbia

BACKGROUND

A significant concern for rural patients is the cost of travel outside of their community for specialist and diagnostic care. Often, these costs are transferred to patients and their families, who also experience stress associated with traveling for care. We sought to examine the rural patient experience by (1) estimating and categorizing the various out of pocket costs associated with traveling for healthcare and (2) describing and measuring patient stress and other experiences associated with traveling to seek care, specifically in relation to household income.

METHODS

We have designed and administered an online, retrospective, cross-sectional survey seeking to estimate the out-of-pocket (OOP) costs and personal experiences of rural patients associated with traveling to access health care in British Columbia. Respondents were surveyed across five categories: Distance Traveled and Transportation Costs, Accommodation Costs, Co-Traveler Costs, Lost Wages, and Patient Stress. Bivariate relationships between respondent household income and other numerical findings were investigated using one-way ANOVA.

RESULTS

On average, costs for respondents were $856 and $674 for transport and accommodation, respectively. Strong relationships were found to exist between the distance traveled and total transport costs, as well as between a patient's stress and their household income. Patient perspectives obtained from this survey expressed several related issues, including the physical and psychosocial impacts of travel as well as delayed or diminished care seeking.

CONCLUSIONS

These key findings highlight the existing inequities between rural and urban patient access to health care and how these inequities are exacerbated by a patient's overall travel-distance and financial status. This study can directly inform policy related efforts towards mitigating the rural-urban gap in access to health care.

Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions

Globally, cardiovascular diseases are the leading cause of disease burden and death. Timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions. In this paper, we study the impact of Brazil's More Doctors Program (MDP) on hospitalizations due to cerebrovascular disease and hypertension. We exploit the geographic variation in the uptake of the MPD and combine coarsened exact matching and difference-in-difference methods to construct valid counterfactual estimates. We use data from the Hospital Information System in Unified Health System, the MDP administrative records, the Brazilian Regulatory Agency, the Ministry of Health, and the Brazilian Institute of Geography and Statistics, covering the years from 2009 to 2017. Our analysis resulted in estimated coefficients of -1.47 (95%CI: -4.04,1.10) for hospitalizations for cerebrovascular disease and -1.20 (95%CI: -5.50,3.11) for hypertension, suggesting an inverse relationship between the MDP and hospitalizations. For cerebrovascular disease, the estimated MDP coefficient was -0.50 (95%CI: -2.94,1.95) in the year of program introduction, -5.21 (95%CI: -9.43,-0.99) and -8.21 (95%CI: -13.68,-2.75) in its third and fourth year of implementation, respectively. Our results further suggest that the beneficial impact of MDP on hospitalizations due to cerebrovascular disease became discernable in urban municipalities starting from the fourth year of implementation. We found no evidence that the MDP led to reductions in hospitalizations due to hypertension. Our results highlight that increased investment in resources devoted to primary care led to improvements in hospitalizations for selected cardiovascular conditions. However, it took time for the beneficial effects of the MDP to become discernable and the Program did not guarantee declines in hospitalizations for all cardiovascular conditions, suggesting that further improvements may be needed to enhance the beneficial impact of the MDP on the level and distribution of population health in Brazil.

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.

Risk factors for avoidable hospitalizations in Canada using national linked data: A retrospective cohort study

Hospitalizations for certain chronic conditions are considered avoidable for adult Canadians given effective and timely primary care management. Individual-level risk factors such as income and health behaviours are not routinely collected in most hospital databases and as a result, are largely uncharacterized for avoidable hospitalization at the national level. The aim of this study was to identify and describe demographic, socioeconomic, and health behavioural risk factors for avoidable hospitalizations in Canada using linked data. A national retrospective cohort study was conducted by pooling eight cycles of the Canadian Community Health Survey (2000/2001-2011) and linking to hospitalization records in the Discharge Abstract Database (1999/2000–2012/2013). Respondents who were younger than 18 years and older than 74 years of age, residing in Quebec, or pregnant at baseline were excluded yielding a final cohort of 389,065 individuals. The primary outcome measure was time-to index avoidable hospitalization. Sex-stratified Cox proportional hazard models were constructed to determine effect sizes adjusted for various factors and their associated 95% confidence intervals. Demographics, socioeconomic status, and health behaviours are associated with risk of avoidable hospitalizations in males and females. In fully adjusted models, health behavioural variables had the largest effect sizes including heavy smoking (Male HR 2.65 (95% CI 2.17–3.23); Female HR 3.41 (2.81–4.13)) and being underweight (Male HR 1.98 (1.14–3.43); Female HR 2.78 (1.61–4.81)). Immigrant status was protective in both sexes (Male HR 0.83 (0.69–0.98); (Female HR 0.69 (0.57–0.84)). Adjustment for behavioural and clinical variables attenuated the effect of individual-level socioeconomic status. This study identified several risk factors for time-to-avoidable hospitalizations by sex, using the largest national database of linked health survey and hospitalization records. The larger effect sizes of several modifiable risk factors highlights the importance of prevention in addressing avoidable hospitalizations in Canada.

Effect of primary health care reforms in the province of Newfoundland and Labrador: Interrupted time-series analysis

OBJECTIVE

To examine the effects of primary health care (PHC) reforms in the Canadian province of Newfoundland and Labrador on ambulatory care-sensitive (ACS) hospitalization rates and mortality.

DESIGN

Interrupted time-series analysis of administrative data.

SETTING

All communities in the province of Newfoundland and Labrador were divided into 3 groups: rural reform (n = 69 143), rural nonreform (n = 228 914), and urban nonreform (n = 197 012). No urban communities introduced PHC reforms.

PARTICIPANTS

All residents of the province who held a valid health card and did not change their address during the 2001-2009 study period were included. Individuals were assigned to 1 of the 3 study groups based on community of residence.

MAIN OUTCOME MEASURES

Hospitalization rates for ACS conditions, hospitalization rates for control conditions, and ACS-related mortality were compared using interrupted time-series models.

RESULTS

Results are reported as rate ratio or odds ratio (OR) (95% CI). In rural reform and rural nonreform communities, there was a decreasing trend in ACS hospitalization rates that preceded reforms (rate ratio of 0.97 [0.94-1.00]) and rate ratio of 0.98 [0.96-1.00], respectively) but no change following reforms. There were no significant changes in the urban group. In all 3 groups, there was a significant increasing trend in ACS-related mortality before reforms (OR of 1.09 [1.02-1.15], OR of 1.10 [1.06-1.13], and OR of 1.09 [1.05-1.14] for rural reform, rural nonreform, and urban communities, respectively), which was reversed after the introduction of reforms (P < .01).

CONCLUSION

Primary health care reforms in Newfoundland and Labrador had no observed effect on ACS hospitalization rates, but a potential effect might have been masked by a decreasing trend that preceded the introduction of reforms. The increase in mortality rates that was reversed after the introduction of reforms cannot be attributed to the reforms because it occurred in all studied populations including those that did not introduce reforms.

Policy implications of regional variations in eye disease detection and treatment on Prince Edward Island: a repeated cross-sectional analysis, 2010-2012

Background

In Canada, government insurance covers eye care services provided by ophthalmologists and other physicians. However, government coverage for services provided by optometrists, non-medical school trained primary eye care providers, varies regionally. Little is known about the impact of a funding model in which ophthalmologist services are government-insured but services provided by optometrists are not, on eye care utilization and eye disease detection and treatment. We aimed to address this question by examining geographic variations in eye care service utilization on Prince Edward Island (PEI).

Methods

PEI physician-billing data from 2010 to 2012 was analyzed across five distinct geographic regions (Charlottetown, Summerside, Prince, Queens & Kings and Stratford). The residential location of patients and practice locations of eye care providers were identified using the first three digits of their respective postal code. Age-standardized rates were computed for comparisons across different regions.

Results

There were six ophthalmologists practicing on PEI, five with offices in Charlottetown. Twenty optometrists practiced on the island with offices across the province. Stratford is closest and Prince farthest from Charlottetown. Age-standardized utilization rates of ophthalmologists per 100 populations were 10.44 in Charlottetown and 10.90 in Stratford, which was significantly higher than in other regions (7.74–8.92; p < 0.05). The disparities were most pronounced amongst the elderly. The prevalence of glaucoma visits was higher in Charlottetown (6.10%) and Stratford (6.38%) and lower in other regions. A similar pattern was observed for the prevalence of cataract visits. While the prevalence of diabetes visits was higher in Prince and Summerside, the utilization of ophthalmologists by people with diabetes was almost twice as high in Charlottetown (6.49%) than in Prince (3.88%).

Conclusions

The observed discrepancies in vision care utilization across geographic regions were likely attributed to barriers in accessing government-insured, geographically concentrated ophthalmologists, as opposed to a reflection of the true differences in eye disease occurrence. The lower prevalence of glaucoma visits in regions farther away from ophthalmologist offices may result in delayed detection and blindness in this population. Encouraging ophthalmologists to work in other areas of the province and/or to publicly fund services provided by optometrists may mitigate the observed disparities.

Trial registration

Not applicable.

Relation between family physician retention and avoidable hospital admission in Newfoundland and Labrador: a population-based cross-sectional study

BACKGROUND

Physician turnover, involving physicians' leaving clinical practice in a specific area, may disrupt continuity of care, leading to poorer health outcomes and greater use of health care services. The purpose of this study was to investigate the relation between family physician retention and avoidable hospital admission for ambulatory-care-sensitive conditions.

METHODS

We conducted a population-based cross-sectional study using provincial health administrative data for residents of Newfoundland and Labrador who held a provincial health card between 2001 and 2009. Five-year family physician retention was calculated by regional economic zone, and residents within economic zones were grouped into tertiles based on physician retention level. We compared hospital admission for ambulatory-care-sensitive conditions among tertiles while adjusting for covariates.

RESULTS

For 475 691 residents of the province, there was a negative relation between physician retention and hospital admission for ambulatory-care-sensitive conditions: residents of areas with moderate or low physician retention had admission rates that were 16.5% (95% confidence interval [CI) 12.6%-20.4%) and 19.9% (95% CI 15.2%-24.7%) higher, respectively, compared to areas with high retention. No relation was found when analysis was limited to those aged 65 years or more.

INTERPRETATION

The findings suggest that high physician retention is associated with lower rates of hospital admission for ambulatory-care-sensitive conditions even after control for other factors. This is consistent with our hypothesis that physician turnover acts to disrupt continuity of care, resulting in higher admission rates.

ACSC Indicator: testing reliability for hypertension

BACKGROUND

With high-quality community-based primary care, hospitalizations for ambulatory care sensitive conditions (ACSC) are considered avoidable. The purpose of this study was to test the inter-physician reliability of judgments of avoidable hospitalizations for one ACSC, uncomplicated hypertension, derived from medical chart review.

METHODS

We applied the Canadian Institute for Health Information's case definition to obtain a random sample of patients who had an ACSC hospitalization for uncomplicated hypertension in Calgary, Alberta. Medical chart review was conducted by three experienced internal medicine specialists. Implicit methods were used to judge avoidability of hospitalization using a validated 5-point scale.

RESULTS

There was poor agreement among three physicians raters when judging the avoidability of 82 ACSC hospitalizations for uncomplicated hypertension (κ = 0.092). The κ also remained low when assessing agreement between raters 1 and 3 (κ = 0.092), but the κ was lower (less than chance agreement) for raters 1 and 2 (κ = -0.119) and raters 2 and 3 (κ = -0.008). When the 5-point scale was dichotomized, there was fair agreement among three raters (κ = 0.217). The proportion of ACSC hospitalizations for uncomplicated hypertension that were rated as avoidable was 32.9%, 6.1% and 26.8% for raters 1, 2, and 3, respectively.

CONCLUSIONS

This study found a low proportion of ACSC hospitalization were rated as avoidable, with poor to fair agreement of judgment between physician raters. This suggests that the validity and utility of this health indicator is questionable. It points to a need to abandon the use of ACSC entirely; or alternatively to work on the development of explicit criteria for judging avoidability of hospitalization for ACSC such as hypertension.

Opportunities and Barriers to Rural, Remote and First Nation Health Services Research in Canada: Comparing Access to Administrative Claims Data in Manitoba and British Columbia

Access to geographically disaggregated data is essential for the pursuit of meaningful rural, remote and First Nation health services research. This paper explores the opportunities and challenges associated with undertaking administrative claims data research in the context of two different models of administrative data management: the Manitoba and British Columbia models. We argue that two conditions must be in place to support rural, remote and First Nation health services research: (1) pathways to data access that reconcile the need to protect privacy with the imperative to conduct analyses on disaggregated data; and (2) a trust-based relationship with data providers.

A Review of Mental Health Approaches for Rural Communities: Complexities and Opportunities in the Canadian Context

Three mental health approaches with potential relevance to rural Canada were reviewed: telepsychiatry, integrated mental health models, and community-based approaches. These approaches have been evaluated in relation to their cost-effectiveness, comprehensiveness, client-centredness, cultural appropriateness, acceptability, feasibility and fidelity; criteria that may vary amidst rural contexts. Collaborative approaches to care, technologies fully integrated into local health systems, multi-sectoral capacity-building, and further engagement with informal social support networks may be particularly promising strategies in rural communities. More research is required to determine rural mental health pathways among diverse social groups, and further, to establish the acceptability of novel approaches in mental health.

Palliative care costs in Canada: A descriptive comparison of studies of urban and rural patients near end of life

BACKGROUND

Significant gaps in the evidence base on costs in rural communities in Canada and elsewhere are reported in the literature, particularly regarding costs to families. However, it remains unclear whether the costs related to all resources used by palliative care patients in rural areas differ to those resources used in urban areas.

AIM

The study aimed to compare both the costs that occurred over 6 months of participation in a palliative care program and the sharing of these costs in rural areas compared with those in urban areas.

DESIGN

Data were drawn from two prior studies performed in Canada, employing a longitudinal, prospective design with repeated measures.

SETTING/PARTICIPANTS

The urban sample consisted of 125 patients and 127 informal caregivers. The rural sample consisted of 80 patients and 84 informal caregivers. Most patients in both samples had advanced cancer.

RESULTS

The mean total cost per patient was CAD 26,652 in urban areas, while it was CAD 31,018 in rural areas. The family assumed 20.8% and 21.9% of costs in the rural and urban areas, respectively. The rural families faced more costs related to prescription medication, out-of-pocket costs, and transportation while the urban families faced more costs related to formal home care.

CONCLUSION

Despite the fact that rural and urban families assumed a similar portion of costs, the distribution of these costs was somewhat different. Future studies would be needed to gain a better understanding of the dynamics of costs incurred by families taking care of a loved one at the end of life and the determinants of these costs in urban versus rural areas.

Comparison of two methods to report potentially avoidable hospitalizations in France in 2012: a cross-sectional study

Background

Potentially avoidable hospitalizations represent an indirect measure of access to effective primary care. However many approaches have been proposed to measure them and results may differ considerably. This work aimed at examining the agreement between the Weissman and Ansari approaches in order to measure potentially avoidable hospitalizations in France.

Methods

Based on the 2012 French national hospital discharge database (Programme de Médicalisation des Systèmes d’Information), potentially avoidable hospitalizations were measured using two approaches proposed by Weissman et al. and by Ansari et al. Age- and sex-standardised rates were calculated in each department. The two approaches were compared for diagnosis groups, type of stay, severity, age, sex, and length of stay.

Results

The number and age-standardised rate of potentially avoidable hospitalizations estimated by the Weissman et al. and Ansari et al. approaches were 742,474 (13.3 cases per 1,000 inhabitants) and 510,206 (9.0 cases per 1,000 inhabitants), respectively. There are significant differences by conditions groups, age, length of stay, severity level, and proportion of medical stays between the Weissman and Ansari methods.

Conclusions

Regarding potentially avoidable hospitalizations in France in 2012, the agreement between the Weissman and Ansari approaches is poor. The method used to measure potentially avoidable hospitalizations is critical, and might influence the assessment of accessibility and performance of primary care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

Avoidable hospitalizations (AH) are hospital admissions for diseases and conditions that could have been prevented by appropriate ambulatory care. We examine regional variation of AH in Switzerland and the factors that determine AH.

Methods

We used hospital service areas, and data from 2008–2010 hospital discharges in Switzerland to examine regional variation in AH. Age and sex standardized AH were the outcome variable, and year of admission, primary care physician density, medical specialist density, rurality, hospital bed density and type of hospital reimbursement system were explanatory variables in our multilevel poisson regression.

Results

Regional differences in AH were as high as 12-fold. Poisson regression showed significant increase of all AH over time. There was a significantly lower rate of all AH in areas with more primary care physicians. Rates increased in areas with more specialists. Rates of all AH also increased where the proportion of residences in rural communities increased. Regional hospital capacity and type of hospital reimbursement did not have significant associations. Inconsistent patterns of significant determinants were found for disease specific analyses.

Conclusion

The identification of regions with high and low AH rates is a starting point for future studies on unwarranted medical procedures, and may help to reduce their incidence. AH have complex multifactorial origins and this study demonstrates that rurality and physician density are relevant determinants. The results are helpful to improve the performance of the outpatient sector with emphasis on local context. Rural and urban differences in health care delivery remain a cause of concern in Switzerland.

Women's Health Care Utilization among Harder-to-Reach HIV-Infected Women ever on Antiretroviral Therapy in British Columbia

Background. HIV-infected women are disproportionately burdened by gynaecological complications, psychological disorders, and certain sexually transmitted infections that may not be adequately addressed by HIV-specific care. We estimate the prevalence and covariates of women's health care (WHC) utilization among harder-to-reach, treatment-experienced HIV-infected women in British Columbia (BC), Canada. Methods. We used survey data from 231 HIV-infected, treatment-experienced women enrolled in the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) study, which recruited harder-to-reach populations, including aboriginal people and individuals using injection drugs. Independent covariates of interest included sociodemographic, psychosocial, behavioural, individual health status, structural factors, and HIV clinical variables. Logistic regression was used to generate adjusted estimates of associations between use of WHC and covariates of interest. Results. Overall, 77% of women reported regularly utilizing WHC. WHC utilization varied significantly by region of residence (P value <0.01). In addition, women with lower annual income (AOR (95% CI) = 0.14 (0.04–0.54)), who used illicit drugs (AOR (95% CI) = 0.42 (0.19–0.92)) and who had lower provider trust (AOR (95% CI) = 0.97 (0.95–0.99)), were significantly less likely to report using WHC. Conclusion. A health service gap exists along geographical and social axes for harder-to-reach HIV-infected women in BC. Women-centered WHC and HIV-specific care should be streamlined and integrated to better address women's holistic health.

Exploring the influence of income and geography on access to services for older adults in British Columbia: a multivariate analysis using the Canadian Community Health Survey (Cycle 3.1)

Existing research on the health care utilization patterns of older Canadians suggests that income does not usually restrict an individual's access to care. However, the role that income plays in influencing access to health services by older adults living in rural areas is relatively unknown. This article examines the relationship between income and health service utilization among older adults in rural and urban areas of British Columbia. Data were drawn from Statistics Canada's Canadian Community Health Survey, Cycle 3.1. Multivariate regression techniques were employed to examine the influence of relative income on accessibility for 3,424 persons aged 65 and over. Results suggest that (1) relative income does not influence access to health care services; and (2) this is true for both urban and rural older adults. The most important and consistent predictors of access in all cases were those that measured health care need.

Predictors of preventable hospitalization in chronic disease: priorities for change

Research in the area of preventable hospitalization, hospital admissions that could otherwise be avoided, provides little guidance in terms of priority areas for change. This synthesis of multiple electronic databases searched systematically for studies related to preventable hospitalization identifies six priority areas for future action in three broad conceptual areas: person priorities (symptom management and supportive relationships), programme priorities (self-management supports and service delivery), and place priorities (local infrastructure and socio-economic opportunities). Attention to these priorities could help reduce preventable hospitalization while simultaneously improving health access and quality of care.

A protocol for determining differences in consistency and depth of palliative care service provision across community sites

Numerous accounts document the difficulty in obtaining accurate data regarding the extent and composition of palliative care services. Compounding the problem is the lack of standardisation regarding categorisation and reporting across jurisdictions. In this study, we gathered both quantitative and spatial--or geographical--data to develop a composite picture that captures the extent, composition and depth of palliative care in the Canadian province of British Columbia (BC). The province is intensely urban in the southwest and is rural or remote in most of the remainder. For this study, we conducted a detailed telephone survey of all palliative care home care teams and facilities hosting designated beds in BC. We used geographic information systems to geocode locations of all hospice and hospital facilities. In-home care data was obtained individually from each of five BC regional health authorities. In addition, we purchased accurate road travel time data to determine service areas around palliative facilities and to determine populations outside of a 1-hour travel time to a facility. With this data, we were able to calculate three critical metrics: (i) the population served within 1 hour of palliative care facilities--and more critically those not served; (ii) a matrix that determines access to in-home palliative care measured by both diversity of professionals as well as population served per palliative team member; and (iii) a ranking of palliative care services across the province based on physical accessibility as well as the extent of in-home care. In combination, these metrics provide the basis for identifying areas of vulnerability with respect to not meeting potential palliative care need. In addition, the ranking provides a basis for rural/urban comparisons. Finally, the protocol introduced can be used in other areas and provides a means of comparing palliative care service provision amongst multiple jurisdictions.

Comparison of the perforation rate for acute appendicitis between nationals and migrants in Taiwan, 1996-2001

OBJECTIVE

Immigrant populations have grown rapidly in recent years in many countries. Immigrant-related healthcare issues have thus become more and more important. The aim of this study was to assess any possible disparity in access to care between migrants and nationals under the national health insurance (NHI) system in Taiwan.

STUDY DESIGN

Retrospective population-based observational study.

METHODS

National population-based data on patients aged ≥20 years in Taiwan under the NHI programme were studied. The frequency of use and expenditure on ambulatory care, inpatient care and emergency care were analysed separately. Ruptured appendicitis was also analysed as an outcome indicator for access to care. Logistic regression and two-part models were applied.

RESULTS

Overall, migrants had a lower rate of healthcare utilization than nationals, and this gap remained consistent from 1996 to 2001. However, using ruptured appendicitis as the outcome indicator, no significant overall difference in access to care was found between nationals and migrants under the NHI programme in Taiwan (odds ratio 1.01, 95% confidence interval 0.93∼1.11).

CONCLUSION

This study found that although migrants had a lower rate of healthcare utilization than nationals, their rate of adverse outcome was similar to nationals when they faced an acute, non-selective emergency condition such as appendicitis. The findings suggest that the use of more dimensional indicators may help to avoid possible misleading inferences on the variation in access to health care in Taiwan.

Patients' perceptions of the quality of care after primary care reform: Family medicine groups in Quebec

OBJECTIVE

To evaluate how a primary care reform, which aimed to promote interprofessional and interorganizational collaborative practices, affected patients' experiences of the core dimensions of primary care.

DESIGN

Before-and-after comparison of patients' perceptions of care at the beginning of family medicine group (FMG) implementation (15 to 20 months after accreditation) and 18 months later.

SETTING

Five FMGs in the province of Quebec from various settings and types of practice.

PARTICIPANTS

A random sample of patients was selected in each FMG; a total of 1046 participants completed both the baseline and follow-up questionnaires.

MAIN OUTCOME MEASURES

Patients' perceptions of relational and informational continuity, organizational and first-contact accessibility, attitude and efficiency of the clinic's personnel and waiting times (service responsiveness), physician-nurse and primary care physician-specialist coordination, and intra-FMG collaboration were assessed over the telephone, mostly using a modified version of the Primary Care Assessment Tool. Additional items covered patients' opinions about consulting nurses, patients' use of emergency services, and patients' recall of health promotion and preventive care received.

RESULTS

A total of 1275 patients were interviewed at the study baseline, and 82% also completed the follow-up interviews after 18 months (n = 1046). Overall, perceptions of relational and informational continuity increased significantly (P < .05), whereas organizational and first-contact accessibility and service responsiveness did not change significantly. Perception of physician-nurse coordination remained unchanged, but perception of primary care physician-specialist coordination decreased significantly (P < .05). The proportion of participants reporting visits with nurses and reporting use of FMGs' emergency services increased significantly from baseline to follow-up (P < .05).

CONCLUSION

This reorganization of primary care services resulted in considerable changes in care practices, which led to improvements in patients' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care.

Rural primary care in Greece: working under limited resources

OBJECTIVE

Establishing sufficient primary health-care services in rural areas is of high interest in developing health systems. The objective of the present study was to describe the state of rural health services, in terms of personnel and equipment, in rural primary care settings in Greece.

DESIGN

A questionnaire was sent to all Greek rural settings (RS) (practices) twice during 2007. The questionnaire included questions about the number of doctors in the practice, their specialty, presence of a nurse, population served and average distance from the regional Health Center and hospital. It also included questions about the average number of consultations per day, home visits, maintenance of medical records and medical equipment.

SETTING

Rural primary care settings in Greece.

PARTICIPANTS

Doctors serving primary care needs during the second half of 2007.

INTERVENTION

s) None.

MAIN OUTCOME MEASURE

s) Data concerning staffing, function and available equipment of the RS have been collected.

RESULTS

Five hundred eighty-two (40.9%) of the rural practitioners replied. Twenty-nine percent of the participants were general practitioners (GPs). Doctors reported average population of responsibility of 2263 citizens and a regular average of 26 consultations per day. A nurse was present in 174 RS (29.5%). Medical records of any form were kept in only 36% of the RS. GPs were more prone to maintain patients files compared with non-specialized doctors. Essential equipment proved to be limited in the majority of the RS.

CONCLUSIONS

Rural practices in Greece report shortages of medical staff (GPs), nursing staff and equipment.

Access to emergency operative care: a comparative study between the Canadian and American health care systems

BACKGROUND

Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States.

METHODS

All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country.

RESULTS

There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24).

CONCLUSION

The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.

Regions, hospitals and health outcomes over time: A multi-level analysis of repeat prevalence among a cohort of health-care workers

BACKGROUND

The relative importance of region, workplace, and individual determinants of health burden is debated.

OBJECTIVE

To model the contribution of hospital characteristics to employee mental and musculoskeletal disorders.

METHODS

We linked employment records of nurses and support services' staff with health records, neighbourhood census, and hospital administrative data. We conducted multi-level logistic regression analyses with three levels: year (I), employee characteristics (II), and hospital characteristics (III).

RESULTS

Northern region hospitals experienced lower disorder prevalences (odds ratios (OR) 0.58, 95% confidence intervals (0.40, 0.82) for mental and 0.56 (0.44, 0.73) for musculoskeletal disorders). Hospitals with yearly workloads of the highest versus lowest quintiles of inpatient days/1000 employee hours (>86.0 vs. <42.6) and surgical cases/1000 employee hours (>10.5 vs. <3.9) had greater odds of mental (1.29 (1.05, 1.57); 1.22 (1.05, 1.42)) and musculoskeletal (1.38 (1.21, 1.58); 1.21 (1.09, 1.34)) disorders.

CONCLUSION

Opportunities exist for reduction in burden with hospital workload reduction. Further exploration of regional effects is needed.

A method to determine spatial access to specialized palliative care services using GIS

Background

Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular.

Methods

Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care.

Results

Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care.

Conclusion

Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners – and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.