Determinants of ambulatory care sensitive conditions hospitalizations – the patients’ perspective

Abstract

Introduction: Ambulatory care sensitive conditions ACSC are health conditions for which hospitalization or emergency care can potentially be avoided through effective prevention, diagnosis and treatment in the ambulatory care setting. In Portugal, ACSC represent 12% of hospitalizations and an estimated financial impact of up to 450 million€. ACSC hospitalizations ACSH have been used as an indirect indicator of access and quality of ambulatory care and have also been suggested to measure integrated health services delivery. Despite previous research on ACSH determinants few studies investigate the patients’ perspective. The aim of this study is to compare the perspectives of patients', healthcare professionals' and evidence on determinants for ACSH. Methods: Firstly a literature review was conducted to map the domains of ACSH determinants, from multiple perspectives patients, caregivers, and health professionals. Then thirteen semi-structured interviews were conducted to include information on the patients’ perspective. Six representatives of patients associations and seven experts on primary health care and internal medicine were interviewed and asked what patients identify as determinants for ACSH. Results: The literature review identified 8 domains of ACSH determinants. The most frequent domains were “Healthcare access”, “Disease self-management” and “Individual characteristics”. While in “Healthcare access” and “Disease self-management” domains the most frequent determinants highlighted “Poor coordination across levels of care” and “Therapeutic adherence” in the “Individual characteristics” domain no determinant predominated. The interviewed representatives of patients associations identified more frequently “Inadequacy of available healthcare services” for the “Healthcare access” domain, “Non-stablished therapeutic plan” for “Disease self-management” domain, and “Dietary habits” for “Lifestyle” domain. Still, professionals interviewed stated equally “Poor coordination across levels of care” and “Difficulty to consult a practitioner” for “Healthcare access”, “Incapability to self-manage disease” for “Disease self-management” domain, as well as problems with “Formal care” for “Social support” domain. Discussion: The patients’ perspective about ACSH determinants is important to understand elements that quantitative methods and healthcare professionals’ perspective cannot explain. “Healthcare access” was the most referred domain on all perspectives being “Poor coordination across levels of care” the most referred determinant, eliciting the needs for integrated healthcare delivery. Other determinants were valued differently. Patients’ representatives elicited determinants related to patients’ daily behavior influencing status of disease. As stated by other studies, healthcare professionals highlighted specific needs of complementary care that are necessary for some patients groups. The limited number of interviews is a recognized limitation. Conclusion: The determinants for ACSH identified in the literature review and interviews differed, despite “Healthcare access” items predominating among these two methods. Based on a literature review and interviews, it appears that listening to the patients’ perspective about determinants for ACSH might allow to prioritize intervention with the focus on minimizing ACSH. Future research: In the future, the most important domains of determinants of ACSH will be assessed through a patient survey to be developed. Specific sets of questions for some ACSC may be justified. Funding acknowledgment WHO European Center for Primary Health Care