Ambulatory Care Sensitive Conditions in Pediatrics: Time for a Reassessment.

Abstract

In this issue of Pediatrics, Krager et al1 examine the relationship between hospitalizations due to ambulatory care sensitive conditions (ACSCs) and the Child Opportunity Index (COI) 2.0.The concept of ACSCs was first set forth by Billings et al2 as a means of examining the potential impact of socioeconomic differences on rates of hospitalizations in New York City on the basis of discharge data of patients aged <65 years. Using a modified Delphi approach, a panel of 6 internists and pediatricians defined ACSCs as follows: “[C]onditions-diagnoses for which timely and effective outpatient care can help to reduce the risks of hospitalizations by either preventing the onset of an illness or condition, controlling an acute episodic illness or condition, or managing a chronic disease or condition.” Billings et al2 also employed small-area analysis as a tool for assessing barriers to outpatient care and for evaluating the effectiveness of programs designed to improve access to care.Bindman et al3 continued the evaluation of ACSCs and small-area analysis by examining discharge data of adults in the state of California. Shi et al4 evaluated patient socioeconomic characteristics associated with hospitalizations due to ACSCs of children and adults in the state of South Carolina. Garg et al5 focused the evaluation of hospitalizations due to ACSCs in the pediatric population, again, in the state of South Carolina. These studies consistently demonstrated a link between increased rates of hospitalizations due to ACSCs and patients who were people of color, publicly insured, or residing in low socioeconomic status areas.Krager et al1 attempt to continue the trend of examining sociodemographic characteristics associated with hospitalizations due to ACSCs. However, these authors employ a novel method using COI 2.0 rather than zip code–level data as a means of evaluating sociodemographic data at the level of a census tract. The COI 2.0 hierarchy consists of 3 domains divided into 9 subdomains and further divided into 29 indicators,6 and it serves as a single composite measurement for nearly all US neighborhoods (∼72 000 census tracts). The COI holds tremendous potential in gauging the healthiness of the environment in which a child is reared. The true power of the COI 2.0 rests in the ability to compare neighborhoods across the United States, potentially allowing researchers and policymakers to examine the efficacy of local, regional, state, and/or federal interventions.However, the limitations of the research project do not rest with the COI 2.0 but rather with the set of ACSCs. As previously mentioned, ACSCs were first published in 1993 by Billings et al2 by employing a modified Delphi method that was composed of 6 internists and pediatricians. The list of pediatric ACSCs was refined by Shi et al4 in 1999 by including ACSCs previously set forth by Billings et al2 minus congestive heart failure, chronic obstructive pulmonary disease, pelvic inflammatory disease, hypertension, and hypoglycemia. Since that time, no major revisions or reevaluations (to this author’s knowledge) have been undertaken to examine the validity of ACSCs. Furthermore, the terms “optimal” and “high-quality” primary care are used in the discussions as a means of mitigating hospitalizations due to ACSCs; however, no definition for these terms has been furnished. Granted, attempting to define and measure optimal or high-quality primary care is not an easy task, nor is the notion that health outcomes are strictly incumbent on the health care provider. Rather, one could argue that positive health outcomes are multifactorial, dependent on the interactions between the health care provider, health care system, health literacy of the parent or guardian, and the environment in which the child resides. Lastly, even with optimal primary care, there will likely always be hospitalizations due to ACSCs despite the best efforts by health care providers.Future research may entail a reanalysis or reenvisioning of ACSCs rather than using a list defined almost 30 years ago. Researchers could perform prospective or retrospective analyses by sampling pediatric hospitalizations from varying socioeconomic domains and determine if certain conditions have higher rates of hospitalizations. Follow-up prospective research could then examine if such conditions are, indeed, reduced with optimal primary care.Primary care providers practicing in lower opportunity census tracts may focus their efforts on mitigating diseases that may be reduced with optimal primary care by current definitions of ACSCs. For example, Krager et al1 demonstrated a hospitalization rate of 29.3 per 1000 children for asthma exacerbations in children from the “very low” opportunity level (Table 3 in ref 1). Clinicians from these opportunity levels may institute the EXHALE program designed by the US Centers for Disease Control and Prevention, providing an asthma action plan or offering attendance to an asthma camp.7 Of course, external factors, such as living near highways, industrial centers, or factories may pose a barrier to decreasing asthma flares. Because of this, understanding what conditions are mitigated with access to primary care and clearly demarcating low- versus high-resourced areas are paramount. Through an iterative process of intervention and reassessment coupled with a more rigorous definition of ACSCs and the power of the COI, we may start to improve the health of the most vulnerable children in our society.