Ambulatory Care Sensitive Hospitalizations Research Articles

Emergency Department Visits and Hospitalizations for the Uninsured in Illinois Before and After Affordable Care Act Insurance Expansion.

We describe changes in emergency department (ED) visits and the proportion of patients with hospitalizations through the ED classified as Ambulatory Care Sensitive Hospitalization (ACSH) for the uninsured before (2011-2013) and after (2014-2015) Affordable Care Act (ACA) health insurance expansion in Illinois. Hospital administrative data from 201 non-federal Illinois hospitals for patients age 18-64 were used to analyze ED visits and hospitalizations through the ED. ACSH was defined using Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQIs). Logistic regression was used to test the effect of time period on the odds of an ACSH for uninsured Illinois residents, controlling for patient sociodemographic characteristics, weekend visits and state region. Total ED visits increased 5.6% in Illinois after ACA implementation, with virtually no change in hospital admissions. Uninsured ED visits declined from 22.9% of all visits pre-ACA to 12.5% in 2014-2015, reflecting a 43% decline in average monthly ED visits and 54% in ED hospitalizations. The proportion of uninsured ED hospitalizations classified as ACSH increased from 15.4 to 15.5%, a non-significant difference. Older uninsured female, minority and downstate Illinois patients remained significantly more likely to experience ACSH throughout the study period. ED visits for the uninsured declined dramatically after ACA implementation in Illinois but over 12% of ED visits are for the remaining uninsured. The proportion of visits resulting in ACSH remained stable. Providing universal insurance with care coordination focused on improved access to home and ambulatory care could be highly cost effective.

Inequalities in pediatric avoidable hospitalizations between Aboriginal and non-Aboriginal children in Australia: a population data linkage study.

BackgroundAustralian Aboriginal children experience a disproportionate burden of social and health disadvantage. Avoidable hospitalizations present a potentially modifiable health gap that can be targeted and monitored using population data. This study quantifies inequalities in pediatric avoidable hospitalizations between Australian Aboriginal and non-Aboriginal children.MethodsThis statewide population-based cohort study included 1 121 440 children born in New South Wales, Australia, between 1 July 2000 and 31 December 2012, including 35 609 Aboriginal children. Using linked hospital data from 1 July 2000 to 31 December 2013, we identified pediatric avoidable, ambulatory care sensitive and non-avoidable hospitalization rates for Aboriginal and non-Aboriginal children. Absolute and relative inequalities between Aboriginal and non-Aboriginal children were measured as rate differences and rate ratios, respectively. Individual-level covariates included age, sex, low birth weight and/or prematurity, and private health insurance/patient status. Area-level covariates included remoteness of residence and area socioeconomic disadvantage.ResultsThere were 365 386 potentially avoidable hospitalizations observed over the study period, most commonly for respiratory and infectious conditions; Aboriginal children were admitted more frequently for all conditions. Avoidable hospitalization rates were 90.1/1000 person-years (95 % CI, 88.9–91.4) in Aboriginal children and 44.9/1000 person-years (44.8–45.1) in non-Aboriginal children (age and sex adjusted rate ratio = 1.7 (1.7–1.7)). Rate differences and rate ratios declined with age from 94/1000 person-years and 1.9, respectively, for children aged <2 years to 5/1000 person-years and 1.8, respectively, for ages 12- < 14 years. Findings were similar for the subset of ambulatory care sensitive hospitalizations, but in contrast, non-avoidable hospitalization rates were almost identical in Aboriginal (10.1/1000 person-years, (9.6–10.5)) and non-Aboriginal children (9.6/1000 person-years (9.6–9.7)).ConclusionsWe observed substantial inequalities in avoidable hospitalizations between Aboriginal and non-Aboriginal children regardless of where they lived, particularly among young children. Policy measures that reduce inequities in the circumstances in which children grow and develop, and improved access to early intervention in primary care, have potential to narrow this gap.Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-016-0706-7) contains supplementary material, which is available to authorized users.

Potentially Preventable Hospitalization among Patients with CKD and High Inpatient Use.

Although patients with CKD are commonly hospitalized, little is known about those with frequent hospitalization and/or longer lengths of stay (high inpatient use). The objective of this study was to explore clinical characteristics, patterns of hospital use, and potentially preventable acute care encounters among patients with CKD with at least one hospitalization. We identified all adults with nondialysis CKD (eGFR<60 ml/min per 1.73 m2) in Alberta, Canada between January 1 and December 31, 2009, excluding those with prior kidney failure. Patients with CKD were linked to administrative data to capture clinical characteristics and frequency of hospital encounters, and they were followed until death or end of study (December 31, 2012). Patients with one or more hospital encounters were categorized into three groups: persistent high inpatient use (upper 5% of inpatient use in 2 or more years), episodic high use (upper 5% in 1 year only), or nonhigh use (lower 95% in all years). Within each group, we calculated the proportion of potentially preventable hospitalizations as defined by four CKD-specific ambulatory care sensitive conditions: heart failure, hyperkalemia, volume overload, and malignant hypertension. During a median follow-up of 3 years, 57,007 patients with CKD not on dialysis had 118,671 hospitalizations, of which 1.7% of patients were persistent high users, 12.3% were episodic high users, and 86.0% were nonhigh users of hospital services. Overall, 24,804 (20.9%) CKD-related ambulatory care sensitive condition encounters were observed in the cohort. The persistent and episodic high users combined (14% of the cohort) accounted for almost one half (45.5%) of the total ambulatory care sensitive condition hospitalizations, most of which were attributed to heart failure and hyperkalemia. Risk of hospitalization for any CKD-specific ambulatory care sensitive condition was higher among older patients, higher CKD stage, lower income, registered First Nations status, and those with poor attachment to primary care. Many hospitalizations among patients with CKD and high inpatient use are ambulatory care sensitive condition related, suggesting opportunities to improve outcomes and reduce cost by focusing on better community-based care for this population.

Potentially avoidable and ambulatory care sensitive hospitalisations among forced migrants: a protocol for a systematic review and meta-analysis

IntroductionThere is an increasing number of forced migrants globally, including refugees, asylum seekers, internally displaced persons and undocumented migrants. According to international law, forced migrants should enjoy access to health...

Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare.

Poor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia. To examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia. This was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included. Continuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles. Outcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician). Beneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups. Among older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.

Younger Dual-Eligibles Who Use Federally Qualified Health Centers Have More Preventable Emergency Department Visits, but Some Have Fewer Hospitalizations.

To determine whether younger dual-eligibles receiving care at federally qualified health centers (FQHCs) have lower rates of ambulatory care sensitive (ACS) hospitalization and emergency department (ED) visits. We used the 100% Medicare Part A and Part B institutional claims from 2007 to 2010 for dual-eligibles younger than 65 years, enrolled in traditional fee-for-service Medicare, who received care at an FQHC or lived in a primary care service area with an FQHC. Our cross-sectional analysis used negative binomial regressions to model ACS hospitalizations and ED visits as a function of prior year FQHC use. The model adjusted for beneficiary age, gender, race, and chronic diseases, as well as county fixed effects, time trends, and race-FQHC use interactions. FQHC use is associated with a decrease in ACS hospitalization rates for whites (2.8 per 1000 persons), but an increase among blacks (2.5 per 1000 persons). FQHC use is also associated with an increase in ACS ED visits, from 27 to 33 more visits per 1000 persons per year, depending on patient race. ACS hospital use is higher for FQHC users than nonusers, but white FQHC users have fewer ACS hospitalizations. More research is needed to understand how this relationship varies within and between centers.

Ambulatory Care-Sensitive Condition Hospitalizations Among Medicare Beneficiaries.

This study examined the association between the distribution of primary care physicians and Medicare beneficiaries' ambulatory care sensitive condition hospitalizations using both statistical and spatial analyses. Data from the 2014 County Health Rankings, 2013-2014 Area Resource File, and the 2014 Food Environment Atlas Data File were integrated to perform county-level ordinary least squares and geographically weighted regression. Analyses were conducted in late 2015. Primary care physician density was found to be negatively associated with Medicare beneficiaries' ambulatory care sensitive condition hospitalization rate in both ordinary least squares (β=-5.88, p=0.0037) and geographically weighted regression models (37.08% of all counties), with the latter model finding significant relationships in the South and Northeast. Preventable hospitalizations are high in areas of the U.S. that have low primary care physician density and other healthcare resources, large non-white populations, high levels of area deprivation, and rural designations.Using geospatial techniques helped document areas of greatest concern for potential intervention. Futureresearch needs to account for these regional differences and target surveillance accordingly.

The financial and health burden of diabetic ambulatory care sensitive hospitalisations in Mexico.

To estimate the financial and health burden of diabetic ambulatory care sensitive hospitalisations (ACSH) in Mexico during 2001-2011. We identified ACSH due to diabetic complications in general hospitals run by local health ministries and estimated their financial cost using diagnostic related groups. The health burden estimation assumes that patients would not have experienced complications if they had received appropriate primary care and computes the associated Disability-Adjusted Life Years (DALYs). The financial cost of diabetic ACSH increased by 125% in real terms and their health burden in 2010 accounted for 4.2% of total DALYs associated with diabetes in Mexico. Avoiding preventable hospitalisations could free resources within the health system for other health purposes. In addition, patients with ACSH suffer preventable losses of health that should be considered when assessing the performance of any primary care intervention.

Ambulatory Care Sensitive Hospitalizations among Medicaid Beneficiaries with Chronic Conditions

ABSTRACTObjectives: This study examined the relationship between ambulatory care sensitive hospitalizations (ACSH) and patient-level and county-level variables. Methods: Utilizing a retrospective cohort approach, multi-state Medicaid claims data from 2007-2008 was used to examine ACSH at baseline and follow-up periods. The study cohort consisted of adult, non-elderly Medicaid beneficiaries with chronic physical conditions, who were continuously enrolled in fee-for-service programs, not enrolled in Medicare, and did not die during the study period (N=7,021). The dependent variable, ACSH, was calculated in the follow-up year using an algorithm from the Agency for Healthcare Research and Quality algorithm. Patient-level (demographic, health status, continuity of care) and county-level (density of healthcare providers and facilities, socio-economic characteristics, local economic conditions) factors were included as independent variables. Multivariable logistic regression models were used to examine the relationship between ACSH and independent variables. Results: In this study population, 8.2% had an ACSH. African-Americans were more likely to have an ACSH [AOR=1.55, 95% CI 1.16, 2.07] than Caucasians. Adults with schizophrenia were more likely to have an ACSH, compared to those without schizophrenia [AOR=1.54, 95% CI 1.16, 2.04]. Residents in counties with a higher number of community mental health centers [AOR=0.88, 95% CI 0.80, 0.97] and rural health centers [AOR=0.98, 95% CI 0.95, 0.99] were less likely to have an ASCH. Conclusions: Programs and interventions designed to reduce the risk of ACSH may be needed to target specific population subgroups and improve healthcare infrastructure.

Socioeconomic conditions, physician supply, and ambulatory care sensitive hospitalization in large Brazilian cities

Ambulatory care sensitive hospitalizations have been used as an indicator of the effectiveness of primary health care. The research involved a descriptive analysis of the evolution of national indicators from 1998 to 2012 and a cross-sectional study of Brazilian municipalities with populations greater than 50,000, by region of the country, for the year 2012, using correlation and linear regression statistical techniques. There was a slight decline in the proportion of ambulatory care sensitive hospitalizations in Brazil. Socioeconomic and demographic factors and physician supply in the healthcare system are associated with the proportion of ambulatory care sensitive hospitalizations, differing by region of the country. Despite advances in the expansion of the Family Health Strategy, some challenges remain, including better distribution of physicians and other health professionals in the country and effective changes in the healthcare model.

Have Racial Disparities in Ambulatory Care Sensitive Admissions Abated Over Time?

Racial disparities in access to care and access to high-quality care have been persistent over many decades. They have been documented in all areas of health care, including ambulatory care. Policy initiatives have been implemented to address disparities and close the gaps in care that minorities face. Less is known about the effectiveness of these polices. To evaluate whether disparities in quality of ambulatory care have abated during the decade of 2000 by answering 2 questions: (1) were there differences in ambulatory care sensitive hospital admissions rates by race?; (2) have these differences been declining over time? Multivariable linear regressions with fixed county effects and robust SEs of longitudinal panel data. A total of 4,032,322 discharges in 172 counties in 6 states during 2003-2009. Prevention Quality Indicators (PQIs) developed by the Agency for Healthcare Research and Quality, by county, and race calculated from the Healthcare Cost and Utilization Project dataset. In 2003 the overall PQI admission rates were higher for African Americans (around 16.5/1000) than for whites (around 15/1000). By 2009, the overall and the chronic PQI admission rates declined significantly (P<0.01) for whites. They either did not decline or increased for African Americans. Acute PQI rates declined significantly for whites and remained stable for African Americans. Policies addressing persisting racial disparities in quality of ambulatory care for African Americans should focus on the chronic PQIs. In addition, efforts should be made to improve data quality for race and ethnicity information on hospital discharge data to enable informed policy evaluation and planning.

Pollution, Poverty, and Potentially Preventable Childhood Morbidity in Central California

To measure ecological relationships between neighborhood pollution burden, poverty, race/ethnicity, and pediatric preventable disease hospitalization rates. Preventable disease hospitalization rates were obtained from the 2012 California Office of Statewide Health Planning and Development database, for 8 Central Valley counties. US Census Data was used to incorporate zip code level factors including racial diversity and poverty rates. The pollution burden score was calculated by the California Office of Environmental Health Hazard Assessment using 11 indicators. Poisson-based negative binomial regression was used for final analysis. Stratification of sample by age, race/ethnicity, and insurance coverage was also incorporated. Children experiencing potentially preventable hospitalizations are disproportionately low income and under the age of 4 years. With every unit increase in pollution burden, preventable disease hospitalizations rates increase between 21% and 32%, depending on racial and age subgroups. Although living in a poor neighborhood was not associated with potentially avoidable hospitalizations, children enrolled in Medi-Cal who live in neighborhoods with lower pollution burden and lower levels of poverty, face 32% lower risk for ambulatory care sensitive condition hospitalization. Children living in primary care shortage areas are at increased risk of preventable hospitalizations. Preventable disease hospitalizations increase for all subgroups, except white/non-Hispanic children, as neighborhoods became more racially diverse. Understanding the geographic distribution of disease and impact of individual and community level factors is essential to expanding access to care and preventive resources to improve the health of children in California's most polluted and underserved region.

A Comparison of Ambulatory Care Sensitive Hospitalizations Among Children With and Without Autism Spectrum Disorder

ObjectiveTo compare the prevalence of hospitalizations for ambulatory care sensitive conditions (ACSC) in children with and without autism spectrum disorder (ASD) and to compare inpatient health care utilization (total charges and length of stay) for the same conditions in children with and without ASD. MethodsThe 2009 Kids' Inpatient Database was used to examine hospitalizations for ACSC in children within 3 cohorts: those with ASD, those with chronic conditions (CC) without ASD, and those with no CC. ResultsThe proportion of hospitalizations for ACSC in the ASD cohort was 55.9%, compared with 28.2% in the CC cohort and 22.9% in the no-CC cohort (P < .001). Hospitalized children with ASD were more likely to be admitted for a mental health condition, epilepsy, constipation, pneumonia, dehydration, vaccine-preventable diseases, underweight, and nutritional deficiencies compared with the no-CC cohort. Compared with the CC cohort, the ASD cohort was more likely to be admitted for mental health conditions, epilepsy, constipation, dehydration, and underweight. Hospitalized children with ASD admitted for mental health conditions had significantly higher total charges and longer LOS compared with the other 2 cohorts. ConclusionsThe proportion of potentially preventable hospitalizations is higher in hospitalized children with ASD compared with children without ASD. These data underscore the need to improve outpatient care of children with ASD, especially in the areas of mental health care and seizure management. Future research should focus on understanding the reasons for increased inpatient health care utilization in children with ASD admitted for mental health conditions.

Using ambulatory care sensitive hospitalisations to analyse the effectiveness of primary care services in Mexico

Ambulatory care sensitive hospitalisations (ACSH) have been widely used to study the quality and effectiveness of primary care. Using data from 248 general hospitals in Mexico during 2001–2011 we identify 926,769 ACSHs in 188 health jurisdictions before and during the health insurance expansion that took place in this period, and estimate a fixed effects model to explain the association of the jurisdiction ACSH rate with patient and community factors. National ACSH rate increased by 50%, but trends and magnitude varied at the jurisdiction and state level. We find strong associations of the ACSH rate with socioeconomic conditions, health care supply and health insurance coverage even after controlling for potential endogeneity in the rolling out of the insurance programme. We argue that the traditional focus on the increase/decrease of the ACSH rate might not be a valid indicator to assess the effectiveness of primary care in a health insurance expansion setting, but that the ACSH rate is useful when compared between and within states once the variation in insurance coverage is taken into account as it allows the identification of differences in the provision of primary care. The high heterogeneity found in the ACSH rates suggests important state and jurisdiction differences in the quality and effectiveness of primary care in Mexico.

Ambulatory Care Sensitive Hospitalizations Through the Emergency Department by Payer: Comparing 2003 and 2009

BackgroundAmbulatory care sensitive hospitalizations (ACSHs) are hospitalizations that may have been preventable with timely and effective outpatient care. Approximately 75% of all ACSHs occur through the emergency department (ED). ACSHs through the ED (ED ACSHs) have significant implications for costs and ED crowding. ObjectiveThis study compares rates of ED ACSHs for 2003 and 2009 among patients 18 to 64 years of age with private insurance, Medicaid, or no insurance. MethodsNationally representative estimates of ED ACSHs, defined by the Agency for Healthcare Research and Quality (AHRQ) prevention quality indicators (PQIs), were generated from the 2003 and 2009 Nationwide Inpatient Samples. Census data were used to calculate direct age- and sex-standardized ACSH rates by non-Medicare payers for both years. ResultsBetween 2003 and 2009, the overall rate of ED ACSHs decreased from 7.6 (95% confidence interval [CI] 7.57–7.75) to 7.3 (95% CI 7.2–7.4) per 1000 18- to 64-year-old non-Medicare patients. ED ASCH rates declined significantly from 42.4 (95% CI 42.0–42.8) to 25.3 (95% CI 25.0–25.6) per 1000 patients with Medicaid, and declined modestly from 3.8 (95% CI 3.8–3.9) to 3.3 (95% CI 3.2–3.4) per 1000 patients with private insurance. However, the ED ACSH rate increased for the uninsured population from 5.4 (95% CI 5.2–5.7) to 6.2 (95% CI 5.9–6.4) per 1000 patients. ConclusionExpansion of Medicaid over the study period was not associated with an increase in ED ACSHs for Medicaid patients. However, an increase in the uninsured population was associated with an increase in the rate of ED ACSH for uninsured patients.

Physician Networks and Ambulatory Care-sensitive Admissions.

Research on the quality and cost of care traditionally focuses on individual physicians or medical groups. Social network theory suggests that the care a patient receives also depends on the network of physicians with whom a patient's physician is connected. The objectives of the study are: (1) identify physician networks; (2) determine whether the rate of ambulatory care-sensitive hospital admissions (ACSAs) varies across networks--even different networks at the same hospital; and (3) determine the relationship between ACSA rates and network characteristics. We identified networks by applying network detection algorithms to Medicare 2008 claims for 987,000 beneficiaries in 5 states. We estimated a fixed-effects model to determine the relationship between networks and ACSAs and a multivariable model to determine the relationship between network characteristics and ACSAs. We identified 417 networks. Mean size: 129 physicians; range, 26-963. In the fixed-effects model, ACSA rates varied significantly across networks: there was a 46% difference in rates between networks at the 25th and 75th performance percentiles. At 95% of hospitals with admissions from 2 networks, the networks had significantly different ACSA rates; the mean difference was 36% of the mean ACSA rate. Networks with a higher percentage of primary-care physicians and networks in which patients received care from a larger number of physicians had higher ACSA rates. Physician networks have a relationship with ACSAs that is independent of the physicians in the network. Physician networks could be an important focus for understanding variations in medical care and for intervening to improve care.

Interspecialty communication supported by health information technology associated with lower hospitalization rates for ambulatory care-sensitive conditions.

Practice tools such as health information technology (HIT) have the potential to support care processes, such as communication between health care providers, and influence care for "ambulatory care-sensitive conditions" (ACSCs). ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization. To date, associations between such primary care practice capabilities and hospitalizations for ambulatory care-sensitive conditions have been primarily limited to smaller, local studies or unique delivery systems rather than nationally representative studies of primary care physicians in the United States. We analyzed a nationally representative sample of 1,819 primary care physicians who responded to the Center for Studying Health System Change's Physician Survey. We linked 3 years of Medicare claims (2007 to 2009) with these primary care physician survey respondents. This linkage resulted in the identification of 123,760 beneficiaries with one or more of 4 ambulatory care-sensitive chronic conditions (diabetes, chronic obstructive pulmonary disease, asthma, and congestive heart failure) for whom these physicians served as the usual provider. Key independent variables of interest were physicians' practice capabilities, including communication with specialists, use of care managers, participation in quality and performance measurement, use of patient registries, and HIT use. The dependent variable was a summary measure of ambulatory care-sensitive hospitalizations for one or more of these 4 conditions. Higher provider-reported levels of communication between primary care and specialist physicians were associated with lower rates of potentially avoidable hospitalizations. While there was no significant main effect between HIT use and ACSC hospitalizations, the associations between interspecialty communication and ACSC hospitalizations were magnified in the presence of higher HIT use. For example, patients in practices with both the highest level of interspecialty communication and the highest level of HIT use had lower odds of ambulatory care-sensitive hospitalizations than did those in practices with lower interspecialty communication and high HIT use (adjusted odds ratio, 0.70; 95% confidence limits, 0.59, 0.82). Greater primary care and specialist communication is associated with reduced hospitalizations for ambulatory care-sensitive conditions. This effect was magnified in the presence of higher provider-reported HIT use, suggesting that coordination of care with support from HIT is important in the treatment of ambulatory care-sensitive conditions.

Health IT and Ambulatory Care Quality

US government investments in health information technology (IT) have focused on giving incentives for digital health records in hospital settings and by individual physicians. We evaluate the omission of ambulatory care centers, by studying the effects of healthcare IT on ambulatory care quality, which we measure using the rate of hospital admissions for conditions identified as sensitive to ambulatory care quality, using data from Medicare and the Nationwide Inpatient Sample. Results from difference-indifferences models that control for location and time fixed effects, as well as observable factors related to healthcare quality and population demographics, indicate that increased ambulatory IT adoption lowers local area ambulatory care sensitive (ACS) hospitalizations, suggesting quality improvements. The magnitudes imply that a 45% increase in ambulatory IT adoption in a county (the average increase over our sample period 2003-2012) lowers the ACS admission rate in that county by about 1.6%.

Association Between Imposition of a Maintenance of Certification Requirement and Ambulatory Care–Sensitive Hospitalizations and Health Care Costs

In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes. To measure associations between the original ABIM MOC requirement and outcomes of care. Quasi-experimental comparison between outcomes for Medicare beneficiaries treated in 2001 by 2 groups of ABIM-certified internal medicine physicians (general internists). One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control. Quality measures were ambulatory care-sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care-sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care. Other outcomes included health care cost measures (adjusted to 2013 dollars). Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, -1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of -$167 (95% CI, -$270.5 to -$63.5; P = .002; 2.5% of overall mean cost). Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

Hospitalizations for ambulatory care-sensitive conditions, Minas Gerais, Southeastern Brazil, 2000 and 2010.

OBJECTIVETo analyze hospitalization rates and the proportion of deaths due to ambulatory care-sensitive hospitalizations and to characterize them according to coverage by the Family Health Strategy, a primary health care guidance program.METHODSAn ecological study comprising 853 municipalities in the state of Minas Gerais, under the purview of 28 regional health care units, was conducted. We used data from the Hospital Information System of the Brazilian Unified Health System. Ambulatory care-sensitive hospitalizations in 2000 and 2010 were compared. Population data were obtained from the demographic censuses.RESULTSThe number of ambulatory care-sensitive hospitalizations declined from 20.75/1,000 inhabitants [standard deviation (SD) = 10.42) in 2000 to 14.92/thousand inhabitants (SD = 10.04) in 2010 Heart failure was the most frequent cause in both years. Hospitalizations rates for hypertension, asthma, and diabetes mellitus, decreased, whereas those for angina pectoris, prenatal and birth disorders, kidney and urinary tract infections, and other acute infections increased. Hospitalization durations and the proportion of deaths due to ambulatory care-sensitive hospitalizations increased significantly.CONCLUSIONSMean hospitalization rates for sensitive conditions were significantly lower in 2010 than in 2000, but no correlation was found with regard to the expansion of the population coverage of the Family Health Strategy. Hospitalization rates and proportion of deaths were different between the various health care regions in the years evaluated, indicating a need to prioritize the primary health care with high efficiency and quality.