Admissions For Ambulatory Care Sensitive Conditions Research Articles

Healthcare Utilization Differences Among Primary Care Patients Using Telemedicine in the Veterans Health Administration: a Retrospective Cohort Study

BackgroundThe COVID-19 pandemic encouraged telemedicine expansion. Research regarding follow-up healthcare utilization and primary care (PC) telemedicine is lacking.ObjectiveTo evaluate whether healthcare utilization differed across PC populations using telemedicine.DesignRetrospective observational cohort study using administrative data from veterans with minimally one PC visit before the COVID-19 pandemic (March 1, 2019–February 28, 2020) and after in-person restrictions were lifted (October 1, 2020–September 30, 2021).ParticipantsAll veterans receiving VHA PC services during study period.Main MeasuresVeterans’ exposure to telemedicine was categorized as (1) in-person only, (2) telephone telemedicine (≥ 1 telephone visit with or without in-person visits), or (3) video telemedicine (≥ 1 video visit with or without telephone and/or in-person visits). Healthcare utilization 7 days after index PC visit were compared. Generalized estimating equations estimated odds ratios for telephone or video telemedicine versus in-person only use adjusted for patient characteristics (e.g., age, gender, race, residential rurality, ethnicity), area deprivation index, comorbidity risk, and intermediate PC visits within the follow-up window.Key ResultsOver the 2-year study, 3.4 million veterans had 12.9 million PC visits, where 1.7 million (50.7%), 1.0 million (30.3%), and 649,936 (19.0%) veterans were categorized as in-person only, telephone telemedicine, or video telemedicine. Compared to in-person only users, video telemedicine users experienced higher rates per 1000 patients of emergent care (15.1 vs 11.2; p < 0.001) and inpatient admissions (4.2 vs 3.3; p < 0.001). In adjusted analyses, video versus in-person only users experienced greater odds of emergent care (OR [95% CI]:1.18 [1.16, 1.19]) inpatient (OR [95% CI]: 1.29 [1.25, 1.32]), and ambulatory care sensitive condition admission (OR [95% CI]: 1.30 [1.27, 1.34]).ConclusionsTelemedicine potentially in combination with in-person care was associated with higher follow-up healthcare utilization rates compared to in-person only PC. Factors contributing to utilization differences between groups need further evaluation.

Acute health care use among children during the first 2.5 years of the COVID-19 pandemic in Ontario, Canada: a population-based repeated cross-sectional study.

The effects of the decline in health care use at the start of the COVID-19 pandemic on the health of children are unclear. We sought to estimate changes in rates of severe and potentially preventable health outcomes among children during the pandemic. We conducted a repeated cross-sectional study of children aged 0-17 years using linked population health administrative and disease registry data from January 2017 through August 2022 in Ontario, Canada. We compared observed rates of emergency department visits and hospital admissions during the pandemic to predicted rates based on the 3 years preceding the pandemic. We evaluated outcomes among children and neonates overall, among children with chronic health conditions and among children with specific diseases sensitive to delays in care. All acute care use for children decreased immediately at the onset of the pandemic, reaching its lowest rate in April 2020 for emergency department visits (adjusted relative rate [RR] 0.28, 95% confidence interval [CI] 0.28-0.29) and hospital admissions (adjusted RR 0.43, 95% CI 0.42-0.44). These decreases were sustained until September 2021 and May 2022, respectively. During the pandemic overall, rates of all-cause mortality, admissions for ambulatory care-sensitive conditions, newborn readmissions or emergency department visits or hospital admissions among children with chronic health conditions did not exceed predicted rates. However, after declining significantly between March and May 2020, new presentations of diabetes mellitus increased significantly during most of 2021 (peak adjusted RR 1.49, 95% CI 1.28-1.74 in July 2021) and much of 2022. Among these children, presentations for diabetic ketoacidosis were significantly higher than expected during the pandemic overall (adjusted RR 1.14, 95% CI 1.00-1.30). We observed similar time trends for new presentations of cancer, but we observed no excess presentations of severe cancer overall (adjusted RR 0.91, 95% CI 0.62-1.34). In the first 30 months of the pandemic, disruptions to care were associated with important delays in new diagnoses of diabetes but not with other acute presentations of select preventable conditions or with mortality. Mitigation strategies in future pandemics or other health system disruptions should include education campaigns around important symptoms in children that require medical attention.

Association between spatial access and hospitalization for ambulatory care sensitive conditions: A retrospective cohort study using claims data

BackgroundHospitalization for ambulatory care sensitive conditions (ACSCs) is potentially preventable with timely and effective primary care but may increase owing to poor access. Spatial access inequalities exist between Japan and other countries. This retrospective cohort study examined the association between admission for ACSC and spatial accessibility to primary care. MethodsWe used claims data and spatial data of 50–74 years-old beneficiaries of the National Health Insurance program in a large city in Japan from April 2013–March 2014 and followed them until March 2015. We used a multilevel Poisson regression model to assess the association between the number of ACSC admissions, the distance to the nearest clinic, and the number of physicians in a given area, adjusting for age, gender, comorbidities, number of visits, and household income. ResultsAmong 126,666 eligible beneficiaries (mean age 65.8 years, 54% were women), 1,793 (1.4%) were hospitalized for ACSCs. The ACSC admission rate was significantly higher in those with a distance to the nearest clinic of >1 km than in those with <0.3 km (incident rate ratio [IRR] 1.32, 95% confidence interval [CI] 1.03–1.69). In the stratified analyses, a longer distance to the nearest clinic was associated with higher ACSC admission rates among women (≥0.3 km and <0.5 km: IRR 1.48, 95% CI 1.01–2.17; ≥0.5 km and <1 km: IRR 1.74, 95% CI 1.19–2.56; >1 km: IRR 1.98, 95% CI 1.29–3.03, respectively) and those aged ≥65 years (≥0.3 km and <0.5 km: IRR 1.38, 95% CI 1.07–1.79; ≥0.5 km and <1 km: IRR 1.38, 95% CI 1.06–1.80; >1 km: IRR 1.48, 95% CI 1.10–1.98). ConclusionUnfavorable spatial access was associated with ACSC admissions, particularly among women and older adults.

Admisiones en los servicios de urgencias y costes económicos relacionados con procesos susceptibles de atención ambulatoria en adultos mayores que viven en centros residenciales

ObjectivesTo assess the frequency of emergency department admissions (EDAs) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalization process and the associated costs. MethodThis multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥65 years old living in care homes in five emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalization were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC. ResultsA total of 2444 ED admissions were analyzed. The patients’ mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was €1408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be €1.2 million. ConclusionsEmergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs toward improving care support in residential settings.

Delirium Due to Potentially Avoidable Hospitalizations Among Older Adults.

Delirium is a common complication during acute care hospitalizations in older adults. A substantial percentage of admissions are for ambulatory care-sensitive conditions (ACSCs) or potentially avoidable hospitalizations-conditions that might be treated early in the outpatient setting to prevent hospitalization and hospital complications. This retrospective cross-sectional study examined rates of delirium among older adults hospitalized for ACSCs. Participants were 39 933 older adults ≥65 years of age admitted from January 1, 2015 to December 31, 2019 to general inpatient units and ICUs of a large Southeastern academic medical center. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale or positive on the Confusion Assessment Method for the Intensive Care Unit during admission, and ACSCs were identified from the primary admission diagnosis using standardized definitions. Generalized linear mixed models were used to examine the association between ACSCs and delirium, compared with admissions for non-ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions. Delirium occurred in 15.6% of admissions for older adults. Rates were lower for ACSC admissions versus admissions for other conditions (13.9% vs 15.8%, p < .001). Older age and higher comorbidity were significant predictors of the development of delirium. Rates of delirium among older adults hospitalized for ACSCs were lower than rates for non-ACSC hospitalization but still substantial. Optimizing the treatment of ACSCs in the outpatient setting is an important goal not only for reducing hospitalizations but also for reducing risks for hospital-associated complications such as delirium.

Severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions among the UK Biobank cohort.

People with mental disorders have worse physical health compared with the general population, which could be attributable to receiving poorer quality healthcare. To examine the relationship between severe and common mental disorders and risk of emergency hospital admissions for ambulatory care sensitive conditions (ACSCs), and factors associated with increased risk. Baseline data for England (N = 445 814) were taken from UK Biobank, which recruited participants aged 37-73 years during 2006-2010, and linked to hospital admission records up to 31 December 2019. Participants were grouped into those with a history of either schizophrenia, bipolar disorder, depression or anxiety, or no mental disorder. Survival analysis was used to assess the risk of hospital admission for ACSCs among those with mental disorders compared with those without, adjusting for factors in different domains (sociodemographic, socioeconomic, health and biomarkers, health-related behaviours, social isolation and psychological). People with schizophrenia had the highest (unadjusted) risk of hospital admission for ACSCs compared with those with no mental disorder (hazard ratio 4.40, 95% CI 4.04-4.80). People with bipolar disorder (hazard ratio 2.48, 95% CI 2.28-2.69) and depression or anxiety (hazard ratio 1.76, 95% CI 1.73-1.80) also had higher risk. Associations were more conservative when including all admissions, as opposed to first admissions only. The observed associations persisted after adjusting for a range of factors. People with severe mental disorders have the highest risk of preventable hospital admissions. Ensuring people with mental disorders receive adequate ambulatory care is essential to reduce the large health inequalities they experience.

Child Opportunity Index and Rehospitalization for Ambulatory Care Sensitive Conditions at US Children's Hospitals.

Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations. Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions. The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75]). Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations.

Emergency department admissions and economic costs burden related to ambulatory care sensitive conditions in older adults living in care homes

ObjectivesTo assess the frequency of emergency department admissions (EDA) for ambulatory care sensitive conditions (ACSC) and non-ACSC among older adults living in care homes (CH), to describe and compare their demographic and clinical characteristics, the outcomes of the hospitalisation process and the associated costs. MethodThis multicenter, retrospective and observational study evaluated 2444 EDAs of older adults ≥ 65 years old living in care homes in 5 emergency departments in Catalonia (Spain) by ACSC and non-ACSC, in 2017. Sociodemographic variables, prior functional and cognitive status, and information on diagnosis and hospitalisation were collected. Additionally, the costs related with the EDAs were calculated, as well as a sensitivity analysis using different assumptions of decreased admissions due to ACSC. ResultsA total of 2444 ED admissions were analysed. The patients’ mean (SD) age was 85.9 (7.2) years. The frequency of ACSC-EDA and non-ACSC-EDA was 56.6% and 43.4%, respectively. Severe dependency and cognitive impairment were present in 56.6% and 78%, respectively, with no differences between the two groups. The three most frequent ACSC were falls/trauma (13.8%), chronic obstructive pulmonary disease/asthma (11.4%) and urinary tract infection (7.4%). The average cost per ACSC-EDA was є1,408.24. Assuming a 60% reduction of ACSC-EDA, the estimated cost savings would be є1.2 million. ConclusionsEmergency admissions for ACSC from care homes have a significant impact on both frequency and costs. Reducing these conditions through targeted interventions could redirect the avoided costs towards improving care support in residential settings.

National Norms for Hospitalizations Due to Ambulatory Care Sensitive Conditions among Adults in the US.

Ambulatory care sensitive conditions (ACSCs) are acute or chronic health issues that lead to potentially preventable hospitalizations when not treated in the outpatient primary care setting. To describe national hospitalization rates due to ACSCs among adult inpatients in the US. A retrospective cross-sectional analysis of the 2018 US National Inpatient Sample (NIS) dataset from the Healthcare Cost and Utilization Project at the Agency of Healthcare Research and Quality was completed in the year 2022. Participants were adult inpatients from community hospitals in 48 states of the US and District of Columbia. ACSC admission rates were calculated using ICD-10 codes and the Purdy ACSC definition. The admission rates were weighted to the US inpatient population and stratified by age, sex, and race. ACSC hospitalization rates varied considerably across age and average number of hospitalizations varied across sex and race. ACSC hospitalization rates increased with age, male sex, and Native American and Black race. The most common ACSCs were pneumonia, diabetes, and congestive heart failure. Previous studies have emphasized the importance of preventable hospitalizations, however, the national rates for ACSC hospitalizations across all ages in the US have not been reported. The national rates presented will facilitate comparisons to identify hospitals and health care systems with higher-than-expected rates of ACSC admissions that may suggest a need for improved primary care services.

Hospital-associated disability due to avoidable hospitalizations among older adults.

Hospital-associated disability (HAD) is a common complication during the course of acute care hospitalizations in older adults. Many admissions are for ambulatory care sensitive conditions (ACSCs), considered potentially avoidable hospitalizations-conditions that might be treated in outpatient settings to prevent hospitalization and HAD. We compared the incidence of HAD between older adults hospitalized for ACSCs versus those hospitalized for other diagnoses. We conducted a retrospective cohort study in inpatient (non-ICU) medical and surgical units of a large southeastern regional academic medical center. Participants were 38,960 older adults 65 years of age admitted from January 1, 2015, to December 31, 2019. The primary outcome was HAD, defined as decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. We used generalized linear mixed models to examine differences in HAD between hospitalizations with a primary diagnosis for an ACSC using standard definitions versus primary diagnosis for other conditions, adjusting for covariates and repeated observations for individuals with multiple hospitalizations. We found that 10% of older adults were admitted for an ACSC, with rates of HAD in those admitted for ACSCs lower than those admitted for other conditions (16% vs. 20.7%, p < 0.001). Age, comorbidity, admission functional status, and admission cognitive impairment were significant predictors for development of HAD. ACSC admissions to medical and medical/surgical services had lower odds of HAD compared with admissions for other conditions, with no significant differences between ACSC and non-ACSC admissions to surgical services. Rates of HAD among older adults hospitalized for ACSCs are substantial, though lower than rates of HAD with hospitalization for other conditions, reflecting that acute care hospitalization is not a benign event in this population. Treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce HAD.

Impact of COVID-19 infection rates on admissions for ambulatory care sensitive conditions: nationwide difference-in-difference design in Japan

ObjectivesSARS-CoV-2 infection (COVID-19) has affected tertiary medical institutions and primary care. Admission for ambulatory care sensitive conditions (ACSCs) is an important indicator of primary care quality. However, no nationwide study,...

Identifying patterns of potentially preventable hospitalisations in people living with dementia

BackgroundOlder Australians make up 46% of all potentially preventable hospitalisations (PPHs) and people living with dementia are at significantly greater risk. While policy reforms aim to reduce PPHs, there is currently little evidence available on what drives this, especially for people living with dementia. This study examines patterns of PPHs in people living with dementia to inform service delivery and the development of evidence-based interventions.MethodsWe used the Victorian Admitted Episodes Dataset from Victoria, Australia, to extract data for people aged 50 and over with a diagnosis of dementia between 2015 and 2016. Potentially avoidable admissions, known as ambulatory care sensitive conditions (ACSCs), were identified. The chi-square test was used to detect differences between admissions for ACSCs and non-ACSCs by demographic, geographical, and administrative factors. Predictors of ACSCs admissions were analysed using univariate and multiple logistic regression.ResultsOf the 8156 hospital records, there were 3884 (48%) ACSCs admissions, of which admissions for urinary tract infections accounted for 31%, followed by diabetes complications (21%). Mean bed-days were 8.26 for non-ACSCs compared with 9.74 for ACSCs (p ≤ 0.001). There were no differences between admissions for ACSCs and non-ACSCs by sex, marital status, region (rural vs metro), and admission source (private accommodation vs residential facility). Culture and language predicted ASCS admission rates in the univariate regression analyses, with ACSC admission rates increasing by 20 and 29% if English was not the preferred language or if an interpreter was required, respectively. Results from the multiple regression analysis confirmed that language was a significant predictor of ACSC admission rates.ConclusionsImproved primary health care may help to reduce the most common causes of PPHs for people living with dementia, particularly for those from culturally and linguistically diverse backgrounds.

The Impact of Rural Hospital Closures and Health Service Restructuring on Provincial- and Community-Level Patterns of Hospital Admissions in New Brunswick.

In the early 2000s, the Province of New Brunswick, Canada, undertook health system restructuring, including closing some rural hospitals. We examined whether changes in geographic access to hospitals and primary care were associated with changes in patterns of hospital use. We described three measures of hospital use for ambulatory care sensitive conditions (ACSCs) among adults 75 years and younger annually during the period 2004–2013 overall, and at the community scale. We described spatial and temporal patterns in: age-standardized hospitalization rates, age-standardized incidence of hospital admissions, and rates of admissions via ambulance. Overall, rates and incidence of hospitalizations for ACSCs declined while admissions via ambulance remained largely unchanged. We observed considerable regional variation in rates between communities in 2004. This regional variation decreased over time, with rural areas demonstrating the sharpest declines. Changes in hospital service provision within individual communities had little impact on rates of ACSC admissions. Results were consistent across urban and rural communities and were robust to analyses that included older patients and those admitted for reasons other than ACSCs. Our results suggest that the restructuring and hospital closures did not result in substantial changes to regional patterns or rates of service use.

Physician- versus practice-level primary care continuity and association with outcomes in Medicare beneficiaries.

To compare physician-level versus practice-level primary care continuity and their association with expenditure and acute care utilization among Medicare beneficiaries and evaluate whether continuity of outpatient primary care at either/both physician or/and practice level could be useful quality measures. Medicare Fee-For-Service claims data for community dwelling beneficiaries without end-stage renal disease who were attributed to a national random sample of primary care practices billing Medicare (2011-2017). Retrospective secondary data analysis at per Medicare beneficiary per year level. We used multivariable linear regression with practice-level fixed effects to estimate continuity of care score at physician versus practice level and their associations with outcomes. We calculated clinician- and practice-level Bice-Boxerman continuity of care index scores, ranging from 0 to 1, using primary care outpatient claims. Medicare expenditures, hospital admissions, emergency department (ED) visits, and readmissions were obtained from the Medicare Beneficiary Summary File: Cost and Utilization Segment. Ambulatory care sensitive conditions (ACSC) were defined using diagnosis codes on inpatient claims. We studied 2,359,400 beneficiaries who sought care from 13,926 physicians. Every 0.1 increase in physician continuity score was associated with a $151 reduction in expenditure per beneficiary per year (p < 0.01), and every 0.1 increase in practice continuity score was associated with $282 decrease (p < 0.01) per beneficiary per year. Both physician- and practice-level continuity were associated with lower Medicare expenditures among small, medium, and large practices. Both physician- and practice-level continuity were associated with lower probabilities of hospitalization, ED visit, admissions for ACSC, and readmission. Primary care continuity of care could serve as a potent value-based care quality metric. Physician-level continuity is a unique value center that cannot be supplanted by practice-level continuity.

Impact of rural hospital closures on hospitalizations and associated outcomes for ambulatory and emergency care sensitive conditions.

The purpose of this paper is to examine the impact of rural hospital closures on age-adjusted hospitalization rates for ambulatory care sensitive condition (ACSC) and emergency care sensitive condition (ECSC) and associated outcomes, such as length of stay and in-hospital mortality in hospital service areas (HSAs) that utilized the closed hospital. We used the State Inpatient Data from the Healthcare Cost and Utilization Project for 9 states from 2010 to 2017 and classified admissions as ACSC or ECSC. We compared age-adjusted admission rates and length of stay (LOS) for ACSC and ECSC rates and age adjusted in-hospital mortality rate for ECSC among rural ZIP codes in HSAs with a closure to rural ZIP codes in HSAs without closures. We used propensity score-weighted regression analysis and event study design. Findings suggest that ACSC admission rates started to increase right before the closure. However, this increase levels off 2 years after closure. LOS for ACSC significantly decreased almost a year after closure. ECSC admissions showed a significant decrease for a few quarters 1 year before the closure. Rural hospital closures were associated with increase in ACSC admissions right before closure and for nearly 2 years post closure as well as decrease in ECSC admissions before closure. As rural hospitals continue to close, efforts to ensure communities affected by these closures maintain access to primary health care may help eliminate increases in costly preventable hospital admissions for ACSC while ensuring access for emergency care services.

Gout and Hospital Admission for Ambulatory Care-Sensitive Conditions: Risks and Trajectories.

To investigate the risks and trajectories of hospital admission for ambulatory care-sensitive conditions (ACSCs) in gout. Among individuals aged 35 years to 85 years residing in Skåne, Sweden, in 2005, those with no doctor-diagnosed gout during 1998 to 2005 (n = 576,659) were followed from January 1, 2006, until a hospital admission for an ACSC, death, relocation outside Skåne, or December 31, 2016. Treating a new gout diagnosis (International Classification of Diseases, 10th revision, code M10) as a time-varying exposure, we used Cox proportional and additive hazard models to estimate the effects of gout on hospital admissions for ACSCs. We investigated the trajectory of hospital admissions for ACSCs from 3 years before to 3 years after gout diagnosis using generalized estimating equations and group-based trajectory modeling in an age-and sex-matched cohort study. Gout was associated with a 41% increased rate of hospital admission for ACSCs (hazard ratio 1.41, 95% CI 1.35-1.47), corresponding to 121 (95% CI 104-138) more hospital admissions for ACSCs per 10,000 person-years compared with those without gout. Our trajectory analysis showed that higher rates of hospital admission for ACSCs among persons with gout were observed from 3 years before to 3 years after diagnosis, with the highest prevalence rate ratio (2.22, 95% CI 1.92-2.53) at the 3-month period after diagnosis. We identified 3 classes with distinct trajectories of hospital admissions for ACSCs among patients with gout: almost none (88.5%), low-rising (9.7%), and moderate-sharply rising (1.8%). The Charlson Comorbidity Index was the most important predictor of trajectory class membership. Increased risk of hospital admissions for ACSCs in gout highlights the need for better management of the disease through outpatient care, especially among foreign-born, older patients with comorbidities.

INCIPIENT DEMENTIA AND RISK OF HOSPITAL ADMISSION FOR AMBULATORY CARE SENSITIVE CONDITIONS IN OSTEOARTHRITIS OF THE PERIPHERAL JOINTS

Purpose: Ambulatory care sensitive conditions (ACSCs) include several chronic (e.g. diabetes, hypertension) and acute (e.g. bleeding gastric ulcer, diarrhoea) conditions that can be effectively managed in the outpatient setting. However, if appropriate and timely ambulatory care is not provided, individuals may need costly in-hospital care which was potentially avoidable. Previous research documented elevated risks of suboptimal care for people with multimorbidity. In this study, we aimed to investigate the associations between incipient dementia and hospital admission for ACSCs among people with osteoarthritis (OA).

Trends in Hospitalizations for Ambulatory Care–Sensitive Conditions During the COVID-19 Pandemic

The association of the COVID-19 pandemic with the quality of ambulatory care is unknown. Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are a well-studied measure of the quality of ambulatory care; however, they may also be associated with other patient-level and system-level factors. To describe trends in hospital admissions for ACSCs in the prepandemic period (March 2019 to February 2020) compared with the pandemic period (March 2020 to February 2021). This cross-sectional study of adults enrolled in a commercial health maintenance organization in Michigan included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period. COVID-19 pandemic (March 2020 to February 2021). Adjusted relative risk (aRR) of ACSC hospitalizations and intensive care unit stays for ACSC hospitalizations and adjusted incidence rate ratio of the length of stay of ACSC hospitalizations in the prepandemic (March 2019 to February 2020) vs pandemic (March 2020 to February 2021) periods, adjusted for patient age, sex, calendar month of admission, and county of residence. The study population included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period, in which 51.3% of person-months (n = 6 547 231) were for female patients, with a relatively even age distribution between the ages of 24 and 64 years. The relative risk of having any ACSC hospitalization in the pandemic period compared with the prepandemic period was 0.72 (95% CI, 0.69-0.76; P < .001). This decrease in risk was slightly larger in magnitude than the overall reduction in non-ACSC, non-COVID-19 hospitalization rates (aRR, 0.82; 95% CI, 0.81-0.83; P < .001). Large reductions were found in the relative risk of respiratory-related ACSC hospitalizations (aRR, 0.54; 95% CI, 0.50-0.58; P < .001), with non-statistically significant reductions in diabetes-related ACSCs (aRR, 0.91; 95% CI, 0.83-1.00; P = .05) and a statistically significant reduction in all other ACSC hospitalizations (aRR, 0.79; 95% CI, 0.74-0.85; P < .001). Among ACSC hospitalizations, no change was found in the percentage that included an intensive care unit stay (aRR, 0.99; 95% CI, 0.94-1.04; P = .64), and no change was found in the length of stay (adjusted incidence rate ratio, 1.02; 95% CI, 0.98-1.06; P = .33). In this cross-sectional study of adults enrolled in a large commercial health maintenance organization plan, the COVID-19 pandemic was associated with reductions in both non-ACSC and ACSC hospitalizations, with particularly large reductions seen in respiratory-related ACSCs. These reductions were likely due to many patient-level and health system-level factors associated with hospitalization rates. Further research into the causes and long-term outcomes associated with these reductions in ACSC admissions is needed to understand how the pandemic has affected the delivery of ambulatory and hospital care in the US.

Unseen patterns of preventable emergency care: Emergency department visits for ambulatory care sensitive conditions.

ObjectiveAdmissions for ambulatory care sensitive conditions (ACSCs) are often used to measure potentially preventable emergency care. Visits to emergency departments with ACSCs may also be preventable care but are excluded from such measures if patients are not admitted. We established the extent and composition of this preventable emergency care.MethodsWe analysed 1,505,979 emergency department visits (5% of the national total) between 1 April 2015 and 31 March 2017 at six hospital Trusts in England, using International Classification of Diseases diagnostic coding. We calculated the number of visits for each ACSC and examined the proportions of these visits that did not result in admission by condition and patient characteristics.Results11.1% of emergency department visits were for ACSCs. 55.0% of these visits did not result in hospital admission. Whilst the majority of ACSC visits were for acute rather than chronic conditions (59.4% versus 38.4%), acute visits were much more likely to conclude without admission (70.3% versus 33.4%). Younger, more deprived and ethnic minority patients were less likely to be admitted when they visited the emergency department with an ACSC.ConclusionsOver half of preventable emergency care is not captured by measures of admissions. The probability of admission at a preventable visit varies substantially between conditions and patient groups. Focussing only on admissions for ACSCs provides an incomplete and skewed picture of the types of conditions and patients receiving preventable care. Measures of preventable emergency care should include visits in addition to admissions.

Delirium due to avoidable hospitalizations among older adults

AbstractBackgroundDelirium is a common complication during the course of acute care hospitalizations in older adults, particularly those with pre‐existing dementia. A substantial percentage of these admissions are for ambulatory care sensitive conditions (ACSCs) or avoidable hospitalizations – conditions that might be treated early in the outpatient setting to prevent hospitalization and its complications. We sought to examine the incidence of delirium among older adults hospitalized for ACSCs.MethodsWe examined admissions for 37,346 older adults 65 years of age admitted from January 1, 2015 to December 31, 2019 to the general inpatient (non‐ICU) units of a large regional Southeastern academic medical center. The primary outcome was delirium defined as a score 2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. Generalized linear mixed models were used to compare rates of delirium between hospitalizations with a primary admission diagnosis for an ACSC, using standardized definitions, versus hospitalization for other non‐ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions.ResultsDelirium occurred in 30.1% of admissions for older adults. Rates were lower for those admitted for ACSCs versus those admitted for other conditions. Older age, higher number of comorbidities, presence of dementia, lower baseline cognitive scores, and lower baseline functional scores were all associated with increased risk of delirium. After adjustment for covariates, risk of delirium was 51% lower for admissions for ACSCs versus admissions for other conditions (odds ratio [OR] = 0.49; 95% CI 0.43, 0.57).ConclusionsRates of delirium among older adults hospitalized for ACSCs were lower than rates of delirium during hospitalization for other conditions, but were still substantial. This indicates that treatment of ACSCs in the outpatient setting could be an important component of efforts to reduce delirium.