Reducing Hospitalisations for Ambulatory Care-sensitive Conditions in Integrated Care Systems

Abstract

Introduction: The reduction of unnecessary hospital admissions is one of the key success factors for integrated care systems. Not least the development of country-specific lists of diagnoses which have been classified and validated by medical experts to be ambulatory care sensitive [1] - meaning that these conditions usually do not need to be treated in the hospital setting - has boosted the attention for this field of intervention. Policy context and objective: In Germany previous studies estimated an amount of 3.7 million hospital admissions which were classified as avoidable which corresponds about 20% of all cases per year [2]. Twenty-two diagnosis groups were worked out as a core list and for each of them medical actions were proposed to reduce correspondent hospital admissions. Strengthening the continuity of ambulatory treatment and providing better access to appropriate professionals in the outpatient sector were considered the most important systemic changes necessary to reduce ambulatory care sensitive hospitalisations. Integrated care systems seem to be the best setting to foster the activities necessary for change whereby the expected efficiency gains can help to partly regain the necessary investments [3]. The results of a comparative analysis of hospitalisation rates for ambulatory care sensitive conditions between Germany (GER) and the integrated care system Gesundes Kinzigtal (GK) give an impression of possible reductions in cases and the corresponding amount of savings on health system level. Targeted population: The regional population which is included in the integrated care contracts of GK and which potentially benefits from the different integrated care activities comprises nearly 33,000 individuals in the southwest of Germany. Although their age and gender distribution is already comparable to the mean in Germany (2011: O-Age GER: 43.8 vs. GK: 43.9; Amount of females GER: 51.2% vs. GK: 51.6%) age-standardized rates of ambulatory care sensitive hospitalisations were calculated to compare the groups more precisely. The results were afterwards projected on the 80.3 million lives of the German Standard Population 2011. Highlights: In GK lower mean hospitalisation rates for 18 of the 22 diagnosis groups of the ambulatory care-sensitive conditions could be observed between 2012 and 2015. This shows that there is a potential for reductions in unnecessary admissions which could partly already be achieved by strengthening ambulatory care in GK. If the same age-standardized rates like in GK are applied to Germany about 950,000 cases would have been avoided per year. Valuating each diagnosis group with the mean costs of these hospital cases in Kinzigtal, 2.7 billion Euro could thereby have been saved in Germany's health system per year. And comparing this difference of 950,000 with the overall estimated potential of 3.7 million preventable cases [2] it seems, that even more can be reached. The biggest difference between Germany and the GK projection was found in back pain (-161,000 cases), ischemic heart diseases (-151,000 cases) and hypertension (-97,000 cases) whereas only in these three diagnosis groups about one billion Euro could have been saved on health system level. In contrast there are also diagnosis groups for which the GK projection would result in slightly higher numbers on system level, e.g. for preventable mental and behavioral disorders (+31,000 cases), depressive disorders (+18,000 cases) and heart failure (+18,000 cases) which should in turn trigger the development of appropriate reactions in GK. Transferability: The results of the comparative analysis prove that efficiency gains by focusing on improvements in the outpatient sector in integrated care systems are possible. Some of the actions of GK related to this issue will be demonstrated and their potential contribution to the largely lower rates of ambulatory care-sensitive hospitalisations will be discussed. Conclusions: If integrated care activities like in GK were provided for all citizens of Germany and similar results could be achieved, nearly one million of hospital cases might already have been prevented and about 17,350 hospital beds would not have been needed. The urgently needed workforce could transfer into the ambulatory and preventive services. Efficiency gains in integrated care systems need more nurses, community workers as well as other health professionals and care coordination between all sectors must be improved. This is recently still hindered by certain factors like especially fragmented remuneration systems. Without changes towards value-based regional care systems it seems impossible to make use of the full potential of the concept of ambulatory care sensitive conditions and to define clear responsibilities for certain treatments.