Ambulatory Care Sensitive Conditions Research Articles

Frequency and Type of Outpatient Visits for Patients With Cardiovascular Ambulatory-Care Sensitive Conditions During the COVID-19 Pandemic and Subsequent Outcomes: A Retrospective Cohort Study.

Background Because the impact of changes in how outpatient care was delivered during the COVID-19 pandemic is uncertain, we designed this study to examine the frequency and type of outpatient visits between March 1, 2019 to February 29, 2020 (prepandemic) and from March 1, 2020 to February 28, 2021 (pandemic) and specifically compared outcomes after virtual versus in-person outpatient visits during the pandemic. Methods and Results Population-based retrospective cohort study of all 3.8million adults in Alberta, Canada. We examined all physician visits and 30- and 90-day outcomes, with a focus on those adults with the cardiovascular ambulatory-care sensitive conditions heart failure, hypertension, and diabetes. Our primary outcome was emergency department visit or hospitalization, evaluated using survival analysis accounting for competing risk of death. Although in-person outpatient visits decreased by 38.9% in the year after March 1, 2020 (10 142 184 versus 16 592 599 in the prior year), the introduction of virtual visits (7 152 147; 41.4% of total) meant that total outpatient visits increased by 4.1% in the first year of the pandemic for Albertan adults. Outpatient visit frequency (albeit 41.4% virtual, 58.6% in-person) and prescribing patterns were stable in the first year after pandemic onset for patients with the cardiovascular ambulatory-care sensitive conditions we examined, but laboratory test frequency declined by 20% (serum creatinine) to 47% (glycosylated hemoglobin). In the first year of the pandemic, virtual outpatient visits were associated with fewer subsequent emergency department visits or hospitalizations (compared with in-person visits) for patients with heart failure (adjusted hazard ratio [aHR], 0.90 [95% CI, 0.85-0.96] at 30 days and 0.96 [95% CI, 0.92-1.00] at 90 days), hypertension (aHR, 0.88 [95% CI, 0.85-0.91] and 0.93 [95% CI, 0.91-0.95] at 30 and 90 days), or diabetes (aHR, 0.90 [95% CI, 0.87-0.93] and 0.93 [95% CI, 0.91-0.95] at 30 and 90 days). Conclusions The adoption and rapid uptake of virtual outpatient care during the COVID-19 pandemic did not negatively impact frequency of follow-up, prescribing, or short-term outcomes, and could have potentially positively impacted some of these for adults with heart failure, diabetes, or hypertension in a setting where there was an active reimbursement policy for virtual visits. Given declines in laboratory monitoring and screening activities, further research is needed to evaluate whether long-term outcomes will differ.

Veteran knowledge, perceptions, and receipt of care following visits to VA emergency departments for ambulatory care sensitive conditions.

Receipt of follow-up care after emergency department (ED) visits for chronic ambulatory care sensitive conditions (ACSCs)-asthma, chronic obstructive pulmonary disease, heart failure, diabetes, and/or hypertension-is crucial. We assessed Veterans' follow-up care knowledge, perceptions, and receipt of care after visits to Veterans Health Administration (VA) EDs for chronic ACSCs. Using explanatory sequential mixed methods, we interviewed Veterans with follow-up care needs after ACSC-related ED visits, and manually reviewed ED notes, abstracting interviewees' documented follow-up needs and care received. We interviewed and reviewed ED notes of 35 Veterans, 12-27 (mean 19) days after ED visits. Follow-up care was completely received/scheduled in 20, partially received/scheduled in eight, and not received in seven Veterans. Among those who received care, it was received within specified time frames half the time. However, interviewees often did not recall these time frames or reported them to be longer than specified in the ED notes. Veterans who had not yet received or scheduled follow-up care commonly did not recall follow-up care instructions, believed that they did not need this care since they were not currently having symptoms, or thought that such care would be difficult to obtain due to appointment unavailability and/or difficulties communicating with follow-up care providers. Among the 28 Veterans in whom all or some follow-up care had been received/scheduled, for 25 cases VA staff reached out to the Veteran or the appointment was scheduled prior to or during the ED visit. VA should prioritize implementing processes for EDs to efficiently communicate Veterans' needs to follow-up care providers and systems for reaching out to Veterans and/or arranging for care prior to Veterans leaving the ED. VA should also enhance practices using multimodal approaches for educating Veterans about recommended ED follow-up care and improve mechanisms for Veterans to communicate with follow-up care providers.

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.

Incipient dementia and avoidable hospital admission in persons with osteoarthritis

ObjectiveTo investigate the associations between incipient dementia (ID) and hospitalization for ambulatory care sensitive conditions (ACSCs) among people with osteoarthritis (OA) of the peripheral joints. MethodsAmong individuals aged 51–99 years residing in Skåne, Sweden, in 2009, we identified those with a doctor-diagnosed OA and no dementia during 1998–2009 (n ​= ​57,733). Treating ID as a time-varying exposure, we followed people from January 1, 2010 or their 60th birthday (whichever occurred last) until hospitalization for ACSCs, death, 100th birthday, relocation outside Skåne, or December 31, 2019 (whichever occurred first). Using age as time scale, we applied flexible parametric survival models, adjusted for confounders, to assess the associations between ID and hospitalization for ACSCs. ResultsThere were 58 and 33 hospitalizations for ACSCs per 1000 person-years among OA people with and without ID, respectively. The association between ID and hospitalization for any ACSCs was age-dependent with higher risk in ages<86 years and lower risks in older ages. Between ages 60 and 100 years, persons with ID had, on average, 5.8 (95% CI 0.9, 10.7), 1.6 (−2.6, 5.9) and 3.1 (2.3, 4.0) fewer hospital-free years for any, chronic and acute ACSCs, respectively, compared with persons without ID. ConclusionsAmong persons with OA, while ID was associated with increased risks of hospitalization for ACSCs in younger ages, it was associated with decreased risk in oldest ages. These results suggest the need for improvement in quality of ambulatory care including the continuity of care for people with OA having dementia.

GLOBAL BURDEN OF DISEASE DUE TO AMBULATORY CARE SENSITIVE CONDITIONS, 1990-2019.

The aim: To evaluate the long-term dynamics of health losses caused by ambulatory care sensitive conditions (ACSCs) to justify the priorities of public policy regarding this group of diseases. Materials and methods: The data used were obtained from the Institute of Health Metrics and Evaluation, the European database "Health for All", for 1990-2019. The study was conducted using bibliosemantic, historical and epidemiological study methods. Results: Disability-adjusted life years (DALYs) due to ACSC over 30 years in Ukraine averaged 5145.4 years per 100,000 population (95% CI 4731.1 -5559.7), which is approximately 14% of DALYs of all reasons without a clear trend of change - compound annual growth rate (CARG) of 0.14%. These five causes -angina pectoris, chronic obstructive pulmonary diseases (COPD), lower respiratory infections, diabetes, and tuberculosis - account for 90% of the disease burden associated with ACSCs. There was an increasing trend in DALYs (CARG varied for different ACSCs in the range of 0.59-1.88%), except for COPD, where the decrease in CARG reached -3.16%. Conclusions: This longitudinal study found a small trend toward increased DALYs due to ACSCs. State measures to influence modified risk factors to reduce the burden of losses from ACSCs proved to be ineffective. To significantly reduce DALYs, a more clear and more systematic healthcare policy regarding ACSCs is needed, which includes a set of primary prevention measures, and organizational and economic strengthening of the primary health care.

Racial and Socioeconomic Characteristics Associated with the use of Telehealth Services Among Adults With Ambulatory Sensitive Conditions.

The COVID-19 pandemic led to a major transition for patients from routine ambulatory-care-based in-person primary care visits to telehealth visits to manage chronic diseases. However, it remains unclear the extent to which individuals access telehealth services and whether such utilization varies along neighborhood characteristics, especially among racial minorities. This study aims to examine the association of outpatient telehealth utilization with sociodemographic, clinical, and neighborhood characteristics among adults with ambulatory care sensitive conditions (ACSCs) during the COVID-19 pandemic. We included adults treated for an ACSC between March 5, 2020, and December 31, 2020, at a single ambulatory-care-based healthcare system, which serves a large population of low-income patients in the South region of the United States (i.e., Memphis, TN, Metropolitan Statistical Area). Telehealth utilization was defined by outpatient procedural codes and providers' notes on the type of visits. Generalized linear mixed models were used to examine the association of sociodemographic, clinical, and neighborhood factors with telehealth utilization in the overall cohort and the racial subpopulations. Among the 13,962 adults with ACSCs, 8583 (62.5%) used outpatient telehealth services. Patients who were older, female, with mental disorders, and who had more comorbidities had higher rates of telehealth services (p < .05). Controlling for covariates, we observed 75.2% and 23.1% increased use of telehealth services among Hispanics and other race groups, respectively, compared to Whites. Patients who commuted more than 30 minutes to health facilities were slightly less likely to use telehealth services [OR: 0.994 (0.991,0.998)]. Racial minorities (Blacks and Hispanics) with mental disorders were more likely to use telehealth service when compared to Whites. We found that among patients being treated for ACSCs, the use of telehealth services was highly prevalent in Hispanic patients in general and were more pronounced among both Hispanics and Black patients who have mental disorders.

Trend in hospitalizations due to ambulatory care-sensitive conditions in the Federal District.

to analyze the trend, according to sex, of Ambulatory Care-Sensitive Conditions in the Primary Health Care of the Federal District, from 2009 to 2019. ecological trend study using ACSC hospitalization data available in the Hospitalization System of the Single Health System. The Prais-Winsten method was used to calculate the annual rate variation, expressed in percentages. The dependent variable was the logarithm of the rates, and the independent one, the years in the time series. the Federal District registered 2,103,951 general hospitalizations, 16.4% of which were due to Ambulatory Care-Sensitive Conditions. Males had a higher rate of hospitalization in the period, and both sexes showed a stationary trend. the time trend of Ambulatory Care- Sensitive Conditions was stationary, but further studies are necessary regarding primary health care coverage.

Primary Care Nurse Practitioner Burnout and ED Use and Hospitalizations Among Chronically Ill Medicare Beneficiaries.

Nurse practitioners (NPs) represent the fastest-growing workforce of primary care clinicians in the United States. Their numbers are projected to grow in the near future. The NP workforce can help the country meet the rising demand for care services due to the aging population and increasing chronic disease burden. Yet, increased burnout among these clinicians may affect their ability to deliver high-quality, safe care. We investigated how NP burnout in primary care practices affects patient outcomes, including emergency department (ED) use and hospitalizations, among older adults with chronic conditions. In 2018-2019, we collected survey data from 1244 primary care NPs from 6 geographically diverse states on their burnout and merged the survey data with data from Medicare claims on ED use and hospitalizations among 467 466 older adults with chronic conditions. 26.3% of NPs reported burnout. Using logistic regression models, we found that with a 1-unit increase in the standardized burnout score, the odds of an ED visit increased by 2.8% (OR = 1.028; P-value = .035); Ambulatory Care Sensitive Conditions (ACSC) ED visit by 3.2% (OR = 1.032; P-value = .019); hospitalization by 3.9% (OR = 1.039; P-value = .001); and ACSC hospitalization by 6.2% (OR = 1.062; P-value = .001). Our findings indicate that if chronically ill older adults receive care in primary care practices with higher NP burnout rates they are more likely to use EDs and hospitals. Policy and practice efforts, such as improving NP working conditions, should be undertaken to reduce NP burnout in primary care practices to potentially prevent acute care use.

Structured Evaluation and Management of Patients with COPD in an Accredited Program.

Chronic obstructive pulmonary disease (COPD) is an ambulatory care-sensitive condition. We compared the impact of care received by patients with COPD at Joint Commission-accredited, disease-specific clinics and primary care clinics at an academic health care systemfrom April 2014 to March 2018. Patients with COPD ≥ 40 years old with ≥ 2 outpatient visits 30 days apart were identified. Baseline demographics, disease-specific performance measures, and health care utilization were compared between groups. Propensity matching was conducted and time to the first emergency department (ED) visit and hospitalization was performed using Cox regression analysis. Of 4646 unique patients with COPD, 1114 were treated at disease-specific clinics and 3532 at primary care clinics. The entire group was predominantly female (58.8 %), non-Hispanic White (74.2 %) with a mean age of 65.4 ± 11.4 years consisting of current (47.6 %) or former smokers (38.4 %). In the disease-specific group, performance measures were performed more frequently, and lower rates of ED visits (hazard ratio [HR]=0.31, 95% confidence interval [CI] 0.18-0.54) and hospitalizations (HR 0.41, 95% CI 0.21-0.79) noted in comparison to the primary care group. In this observational study, the implementation of achronic disease management program through accredited disease-specific clinics for patients with COPD was associated with reduced all-cause ED visits and hospitalizations.

Elderly Mortality due to Ambulatory Care Sensitive Conditions and Primary Health Care Coverage in the Federal District.

To describe the mortality coefficients of elderly due to primary care sensitive conditions, from 2008 to 2018, and determine its association with the coverage of the Primary Health Care (Family Health Strategy and Basic Care models) in the Federal District. Ecological time series of mortality in Federal District elderly, from 2008 to 2018. The Poisson regression model was applied, considering as significant those with p<0.05, with a CI of 95%. There were 70,503 deaths. There was a decrease in the risk of death of elders due to cardiovascular diseases and diabetes. Higher primary care coverage decreased the chance of death by sensitive conditions, both in Basic Care (OR: 0.994, CI: 0.990-0.998) and in the Family Health Strategy (OR: 0.997, CI: 0.995-0.999). Primary Care coverage was associated with a lower chance of death of the elderly due to Ambulatory Care Sensitive Conditions, especially in Basic Care.

Elderly Mortality due to Ambulatory Care Sensitive Conditions and Primary Health Care Coverage in the Federal District

RESUMO Objetivos: Descrever os coeficientes de mortalidade entre idosos por condições sensíveis, de 2008 a 2018, e verificar a associação com a cobertura da Atenção Primária à Saúde (Modelo Estratégia Saúde da Família e Atenção Básica) no Distrito Federal. Métodos: Estudo ecológico tipo série temporal da mortalidade dos idosos no Distrito Federal, entre 2008 e 2018. Para análise das associações, aplicou se o modelo de regressão Poisson, sendo consideradas significantes as que apresentaram p&lt;0,05, com IC de 95%. Resultados: Houve70.503 óbitos. Observou-se diminuição do risco de morrer dos idosos por doenças cardiovasculares e diabetes. A cobertura da Atenção Primária diminuiu a chance de morrer por condições sensíveis tanto na Atenção Básica (OR: 0,994, IC: 0,990-0,998) quanto na Estratégia Saúde da Família (OR: 0,997, IC: 0,995-0,999). Conclusões: A cobertura de Atenção Primária foi associada a menor chance de morrer dos idosos por condições sensíveis à Atenção Primária, sobretudo na Atenção Básica.

Trend in hospitalizations due to ambulatory care-sensitive conditions in the Federal District

RESUMO Objetivos: analisar a tendência das Internações por Condições Sensíveis à Atenção Primária por sexo no Distrito Federal, no período de 2009 a 2019. Métodos: estudo ecológico de tendência com dados de ICSAP disponíveis no Sistema de Internações Hospitalares do Sistema Único de Saúde. Utilizou-se o método de Prais-Winsten para o cálculo da variação percentual anual das taxas. A variável dependente foi o logaritmo das taxas; e a variável independente, os anos da série temporal. Resultados: o Distrito Federal registrou 2.103.951 internações gerais, sendo 16,4% Internações por Condições Sensíveis à Atenção Primária. O sexo masculino obteve a maior taxa de internação em todo o período, e houve tendência estacionária tanto para o sexo masculino quanto para o sexo feminino. Conclusões: as tendências temporais das Internações por Condições Sensíveis à Atenção Primária mostraram-se estacionárias, porém ressalta-se a necessidade de estudos de correlação com a cobertura da Atenção Primária à Saúde.

Potentially preventable hospitalizations and super-utilization of inpatient services among patients with chronic kidney disease in Hawaiʻi

BackgroundChronic kidney disease (CKD) is linked to high morbidity and mortality and increased hospitalization burden. If appropriately managed in the outpatient setting, ambulatory care-sensitive conditions (ACSCs) do not lead to hospitalization. Hospitalizations due to ACSCs are considered as potentially preventable hospitalizations. Patients with recurrent hospitalizations are considered as super-utilizers of inpatient services. The aim of this study is to determine prevalence of potentially preventable hospitalizations and super-utilization of inpatient services among patients with CKD in Hawaiʻi.MethodsHawaiʻi statewide inpatient data (2015–2017) were used to identify adult CKD patients with hospitalizations during a 12-month period from the first recorded date of CKD. The associations between the potentially preventable hospitalizations and super-utilization and other key patient demographic and clinical variables (sex, age, ethnicity, insurance type, Charlson comorbidity index (CCI), county of residence, and homelessness indicator) were analyzed using bivariate analysis. Multivariable logistic regression was utilized to assess the associations between the potentially preventable hospitalizations and patient variables.ResultsApproximately 2% of patients reported potentially preventable hospitalizations, and a total of 12.3% patients reported super-utilization. Out of all CKD-specific ACSC hospitalizations, 74.2% were due to heart failure and 25.8% were due to hyperkalemia. Patients who reported super-utilization were more likely to report potentially preventable hospitalization (OR: 5.98, 95%CI: 4.50–7.93) than patients who did not report super-utilization.ConclusionThis study showed prevalence of potentially preventable hospitalizations and high inpatient utilization among CKD patients in Hawaiʻi. Heart failure and hyperkalemia were the two major causes of CKD-specific ACSC hospitalizations in this cohort. Effective strategies should be employed to improve the outpatient CKD management to reduce hospitalizations and in turn reduce cost.

European immigrant health policies, immigrants’ health, and immigrants’ access to healthcare

ObjectiveEvidence indicates presence of immigrant health disparities in the European Union (EU) and the United States (US). We examined the association between immigrant health policies and the gap in health status, unmet needs and service use between immigrants and citizens, in the EU and US. MethodsWe used the Migrant Integration Policy Index (MIPEX), European Health Interview Survey, and National Health Interview Survey for 2014. Our independent variables of interest were MIPEX Health strand score and citizenship. Our dependent variables were four measures of health status (self-reported poor health; severely limited in general activities; two or more comorbidities; one or more ambulatory care sensitive conditions) and four measures of health access and utilization (unmet need due to non-financial reasons; could not afford needed health care; one or more primary care visits last year; any hospitalization last year). We conducted linear probability models and presented the marginal effects of each outcome in percentage points. FindingsWe found that immigrant-friendly health policies were significantly associated with better health and less unmet need due to non-financial reasons. ConclusionOur findings supported the promotion of immigrant-friendly and a ‘Health-in-All Policies’ (HiAP) approach to preserve the health of immigrants.

BETTER NP PRACTICE ENVIRONMENTS REDUCE HOSPITALIZATION DISPARITIES AMONG DUALLY ENROLLED PATIENTS

Abstract Adults dually-enrolled in Medicare and Medicaid experience twice as many hospitalizations and higher rates of ambulatory care-sensitive conditions (ACSCs) – such as coronary artery disease [CAD] and diabetes, compared to Medicare-only patients. Nurse practitioners (NPs) are well-positioned to address care needs of dually-eligible patients, yet NPs often work in unsupportive clinical practice environments. The purpose of this study was to examine the association between the NP primary care practice environment and disparities in all-cause hospitalizations between dually-eligible and Medicare-only patients with ACSCs. Using linked secondary cross-sectional data from the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) and Medicare claims files, we examined 189,420 patients with CAD and/or diabetes (19.1% dually-eligible, 80.9% Medicare-only), cared for in 470 practices employing NPs across four states (PA, NJ, CA, FL) in 2015. After adjusting for patient and practice characteristics, dually-eligible patients in poor practice environments had the highest odds of being hospitalized compared to their Medicare-only counterparts (OR 1.60, CI: 1.49-1.71). In mixed practice environments, dually-eligible patients had approximately 48% higher odds of a hospitalization (OR 1.48, CI 1.31-1.68), while in the best practice environments, dually-eligible patients had approximately 37% higher odds (OR 1.37, CI 1.21-1.57, p &amp;lt; .001). As policymakers look to improve outcomes and reduce costs among dually-eligible patients, addressing a modifiable aspect of care delivery in NPs’ clinical practice environment is a key opportunity to reduce hospitalization disparities. Yet further efforts are needed to address remaining disparities by meeting patients’ health-related social needs, such as poverty and access to care.

Integrated [Primary +] Memory Care Clinic.

The Integrated Memory Care Clinic (IMCC) is a model of care for people living with dementia directed by advanced practice registered nurses. The post-diagnosis model incorporates the expertise of nursing, social work and nurse practitioners certified in gerontology, palliative care and/or geriatric psychiatry. The Clinic nurse practitioners provide comprehensive and coordinated primary care for dementia and other stable chronic conditions and episodic care for minor acute illnesses. Care delivery is structured to maximize ongoing dialogue with patients and their caregivers during office visits and by phone and patient portal access. The Clinic provides a number of services to care partners, including an after-hours line, stage-based educational groups, and a monthly support group. The IMCC aims to reduce the overall burden of dementia by partnering with affected individuals and their caregivers in the co-production of care. Now at full capacity, the IMCC serves 525 active patients and their care partners with 1.3 FTE primary care nurse practitioners. The mean age is 78.6 years; most are female (63%); and 42% identify as a racial minority. The majority of patients are moderate (27% early-moderate; 36% late-moderate) stage of dementia clinical syndrome. The mean monthly rate of hospital admissions for ambulatory care sensitive conditions in 2022 is 1.42%. The published rate for this population is 13-15%. Finally, the model is financially neutral in a fee-for-service environment. Open in 2015, the IMCC has combined primary care and dementia care in one clinical practice. The IMCC developed strong rapport and trust with patients and families to achieve outstanding health outcomes. The model is an American Academy of Nursing Emerging Edge Runner, recognized by NCQA as a Patient Centered Medical Home, recognized as a Level 2 Age-Friendly Health System participant, and a Best Practice Exemplar by the Institute for Patient- and Family-Centered Care.

Sickle Cell Disease May Qualify As an Ambulatory Care Sensitive Condition

Background Ambulatory care sensitive conditions (ACSCs) are conditions for which outpatient care can potentially prevent hospital visits.[i] Effective primary care is associated with lower hospitalization for ACSCs. These hospitalizations are also referred to as avoidable hospitalization.[ii] [iii] We hypothesized that sickle cell disease (SCD) qualifies as an ACSC. We partly tested that hypothesis in the context of an intense primarily ambulatory case management program that also includes urgent and inpatient management components. Methods As part of a SCD Adult Medical Home with multiple interventions, we assigned Community Health Workers (CHWs), called Patient Navigators (PNs), as case managers. A PN (one of two in 2018, and one of three in 2019, 2020, and 2021) was assigned to each of the program's top 50 highest utilizers, but also began periodically managing other patients ad hoc in 2019 (All adult patients, N=537 in 2017 to N=641 in 2021). Activities focused on education to improve self-care, assisting patients with medical appointments, and accessing services to combat adverse social determinants. PNs strove to reduce avoidable emergency department (ED) visits and hospitalizations. Interventions and visit activity included telephone, face-to-face clinic, face-to-face ED, face-to-face inpatient, or face-to-face community contact (restricted to telecommunication by COVID). Data and analyses from 2017 to 2021 included: 1) Spearman's correlation of inpatient discharges with outpatient visits; 2)Spearman's correlation of annual ED visits with annual outpatient visits; 3)calculation of ED Reliance Ratio (ERR, defined as ED visits/ED + ambulatory + inpatient visits), Spearman's correlation of ERR with annual costs, and ANOVA test for significance of ERR decreasing; 4) Spearman's correlation between costs and Inpatient discharge, and ANOVA test for significance of inpatient discharge decreasing. Results 1)Inpatient discharges started to drop with the increased outpatient visits in 2018 for all patients. Due to COVID-19, no significant inverse correlation was observed. However, an inverse Correlation between Inpatient Discharge vs. Outpatient Visit for top 50 utilizers was statistically significant (Spearman R=-0.17, p-value=0.02). 2) Spearman correlation did not show significant inverse correlation between ED_usage and outpatient visit for all patients due to suspected COVID effects. However, annual ED visit is almost inversely correlated with annual outpatient visits for the top 50 utilizers (Spearman R=-0.13, p =0. 05). 3)Total costs correlated with the ERR for 2017-2021, both for each year's top utilizers (Spearman R=0.40, p <0.0001), and for all patients (Spearman R=0.44, p<0.0001). ERR has been significantly decreased from 2017 to 2021 for all patients (ANOVA P=0.0089<0.05) and for top 50 utilizers (ANOVA P<0.0001). 4)In addition, the inpatient discharge positively correlated with total cost both for each year's top utilizers (Spearman R=0.70, p <0.0001), and for all patients (Spearman R=0.71, p<0.0001). The number of Inpatient hospitalizations decreased significantly. ANOVA shows p<0.0001 for both all patients and for top 50 utilizers. Conclusions Sickle cell disease appears to behave as an ACSC in our SCD sample. An intervention led to fewer ED visits and avoidable hospitalization. Annual total costs decreased accordingly during that same period. But some statistically expected utilization relationships were not observed. Future post-COVID utilization may confirm these findings, and studies of ACSC interventions with control groups in SCD patients may increase the validity of our before-after findings of intervention effects. 1. AHRQ Quality Indicators. Guide to prevention quality indicators: hospital admission for ambulatory care sensitive conditions. Rockville: Agency for Healthcare Research and Quality; 2001. AHRQ Pub. No. 02-R0203. 2. Gao J, Moran E, Li YF, et al. Predicting potentially avoidable hospitalizations. Med Care 2014 Feb;52(2):164-71 3. Chartbook on Care Coordination: Potentially Avoidable Hospitalizations. Agency for Healthcare Research and Quality. https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure3.html Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Association between patient-reported social, behavioral, and health factors and emergency department visits in high-risk VA patients.

To identify patient-reported social risk, behavioral, and health factors associated with emergency department (ED) utilization in high-risk Veterans Affairs (VA) patients. Patient survey, VA, Medicare data. Prospective cohort study using multivariable logistic regression to identify patient-reported factors associated with all-cause and ambulatory care sensitive condition (ACSC)-related ED visits among VA patients at high risk for hospitalization or death. Patient-reported measures derived from a 2018 survey sent to 10,000 VA patients; clinical and demographic characteristics derived from VA data; ED visits derived from VA and Medicare claims. Among 4680 survey respondents, 52.5% and 16.3% experienced an all-cause or ACSC-related ED visit in the following year, respectively. An ED visit was more likely among individuals with functional status limitations (6.0% points (Confidence Interval [CI] 0.017-0.103)) and transportation barriers (5.2% points [CI 0.005-0.099]). An ACSC-related ED visit was more likely among individuals with functional status limitations (3.2% points [CI 0.003-0.062]) and self-rated poorer health (7.4% points (CI 0.030-0.119) poor; 6.2% points (CI 0.029-0.096) fair; 4.1% points (CI 0.009-0.073) good; compared with excellent/very good). Patient-reported factors not present in most electronic health records were significantly associated with future ED visits in high-risk VA patients.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions.

Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations. We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating. Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating. We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees. Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

Competition and quality of care under regulated fees: evidence from Ghana

BackgroundHow competition affects the quality of care is still not well understood empirically because of limited and mixed results. This study examined whether competition leads to higher or lower quality health outcomes in Ghana.MethodsWe used administrative claims data of hypertension patients for 2017 – 2019 (36 months), and an instrumental variable method to examine the effect of competition, measured as an increase in district doctor-to-population ratio on hospital-level ambulatory care sensitive condition hospitalization and in-hospital death rates.ResultsOverall, we found that an increase in doctor density improves the quality of care for hypertension patients in Ghana. That is, when there are more doctors, fewer patients are hospitalized, and the risk of in-hospital deaths decreases. This result is robust to analyses at the individual and district population levels for ambulatory care sensitive hospitalizations rate.ConclusionsOur findings suggest that in the presence of physician-induced demand, competition can lead to improvement in the quality of care, possibly through improved access to healthcare and increased physician time and contact per patient. Future health policies need to consider possible welfare benefits of induced medical services and training more doctors.