Hospitalizations for Ambulatory Care–Sensitive Conditions: Where Do We Go From Here?

Abstract

In this issue of Ambulatory Pediatrics, Agha and colleagues demonstrate that lower socioeconomic status, measured by neighborhood income, is associated with higher hospitalization rates for ambulatory care–sensitive conditions (ACSC) among children born in Toronto between 1993 and 2001. Their findings are consistent with prior research that has used census information, hospital discharge files, indices of clinician supply, and insurance claims to demonstrate a relationship between social disadvantage or limited access to health care and higher rates of ACSC hospitalization in children. Many researchers have assessed the association between social factors, delivery system characteristics, and ACSC hospitalizations over the last 10 years because the hypothesis that timely ambulatory care can prevent unnecessary hospitalizations has an intuitive appeal, and because rates of ACSC hospitalization can be easily measured from claims data. However, this research has proceeded without a critical assessment of 3 underlying assumptions about the meaning and use of ACSC: (1) that ACSC hospitalizations can in fact be prevented by timely ambulatory care; (2) that the forces associated with ACSC hospitalizations are distinct from those that affect hospitalizations for other reasons; and (3) that interventions at the level of the child, the clinic, or the delivery system as a whole can reduce the incidence of ACSC hospitalizations. Existing research does not conclusively support any of these assumptions. First, the term ambulatory care–sensitive conditions may be a misnomer. The commonly used list of ACSC in children includes acute illnesses such as pneumonia and gastrointestinal illnesses as well as chronic conditions such as asthma and seizure disorders. This list of ACSC was based on expert consensus about conditions for which early treatment might prevent hospitalizations, but little evidence supports this belief. Although some studies have found that children with ACSC hospitalizations have lower previous use of ambulatory care than children not hospitalized for these conditions, others have found similar or higher rates of ambulatory care for children later