Ambulatory Care Sensitive Conditions in Portugal: Is there room for improvement?

Abstract

Introduction: The healthcare systems worldwide face a challenge posed by the increasing life expectancy, the growing prevalence of non-communicable diseases and the resulting increased demand for resources(1). The integration of care, with the purpose of increasing quality and access (among others) has been widely discussed as a possible solution in this context(1). The Ambulatory Care Sensitive Conditions (ACSC) have proven to be a valid indicator of both Primary Care access and quality(2). In Portugal there is no framework on ACSC or any knowledge of the magnitude of these admissions(3). Objectives • Determine and characterize the ACSC admissions in Portugal. • Characterize the historic evolution of the rate of admissions for ACSC. • Evaluate the impact of the utilization of different lists of ACSC. Methods: The authors undertook an observational, descriptive and analytic study which analyzed data from 4.754.560 hospital admissions of mainland Portuguese residents. The data was sourced from the national admissions databases, from 2007 through 2011. The ACSC admissions were identified according to the Canadian Institute for Health Information(CIHI)(4) and the Spanish list(5). The rates for admission were calculated using the National Statistics Institute’s population estimates for the given year, detailed by municipality. Results: The national rate of admissions for ACSC, according to the CIHI list, has steadily decreased since 2007, from 244,2 to 218,5 (adm/100.000). This was not similar using the Spanish list neither in number nor tendency. It varied from 1539,6 in 2007 increasing to 1608,3 in 2009 and decreasing in 2011 to 1577,5 (adm/100.000). In 2011 the admissions for ACSC accounted for 4,4% and 31,8% of the admissions for medical causes according to the CIHI and Spanish lists respectively. In the CIHI list the most frequent conditions were heart failure (23,3%) and COPD (21,5%), while according to the Spanish list they were Pneumonia (24,2%) and hypertensive heart disease (21,2%). 14th International Conference on Integrated Care, Brussels, April 2-4 2014 International Journal of Integrated Care – Volume 14, 01 October – URN:NBN:NL:UI:10-1-116212 – http://www.ijic.org/ Among the municipalities, according to, the CIHI list, the admission rates for ACSC varied from 51,2 to 732,5 (adm/100.000) (mean 225,5 SD 92,9) and from 720,0 to 3705,6 (adm/100.000) (mean 1733,5 SD 488,1) in the Spanish list. After splitting the municipalities by quintiles it was possible to establish improvement scenarios (up the ladder/all the best)(6), which resulted in estimated reductions in ACSC admission rates between 20% and 45% for the CIHI list and between 13% and 27% for the Spanish list. Discussion/Conclusion. The lists are fundamentally different, while the Spanish includes conditions sensitive to primary prevention, early diagnosis/treatment as well as chronic conditions, the CIHI list includes only chronic conditions. This explains the difference in the number of cases. Therefore the scope of the assessment is much broader in the Spanish list. The inclusion and exclusion criteria are also different, for example, in the Spanish list, the admissions for cardiovascular conditions with cardiac procedures are not excluded. For these reasons a further discussion on the scope of the evaluation of the ACSC, as well as the specificity of the code list, needs to take place in Portugal. There are important regional differences that should be addressed from a policy standpoint, once there are regional clusters of under-average performance. The potential for improvement therefore exists.