Ambulatory Sensitive Conditions Research Articles

Predicting Mental Health Hospitalizations Among First Nations Adults in Residential Treatment

Indigenous peoples in Canada experience disproportionately higher rates of hospitalization for mental health and substance use concerns than non-Indigenous populations. Ambulatory care sensitive conditions are community-level markers of mental illness which can theoretically be managed through community-based health services, and therefore should not require urgent care services. Previous mental health related ambulatory sensitive conditions have included psychotic and mood disorders; however, limited research has explored these relationships of increased hospitalization among specific health disorders with Indigenous populations. This study analyzed predictors of prior mental health hospitalizations among a predominately First Nations population seeking residential treatment for substance use. We hypothesized that increased co-morbid mental health concerns would predict increased hospitalizations for mental health concerns, and this relationship would be moderated by higher Adverse Childhood Experience (ACE) scores. Logistic regression showed that for every increase in each reported mental health concern, the odds of prior hospitalization was 1.6 times higher among this sample, although ACEs did not moderate this relationship. Participants with depressive, anxiety-related, psychotic, and personality-related disorders reported proportionally more hospitalization. Although study results suggest ACEs are not a useful predictor of hospitalization, their presence has previously shown to exacerbate co-morbid concerns, and thus, may influence prior hospitalization history indirectly. Further research can explore relationships between exposure to childhood trauma and hospitalization, particularly in consideration of access to tertiary mental health services.

Better Care, Same Cost - Reducing Unplanned Care for Multi-visit Patients: A Payer-Provider Model.

Many interventions implemented for multi-visit patients (MVP) have been developed to address patient-centric needs of these individuals and reduce unplanned care for ambulatory-sensitive conditions. More rigorous research is needed to better understand the impact of these interventions on changes in care utilization including unplanned care. To evaluate the impact of the Enhanced Care Program (ECP), a payer-provider collaborative model, on unplanned care use and cost of care. Using propensity methods, a comparison group was constructed using insurer membership files. Comparisons were performed using a difference-in-differences analysis. Patients enrolled in ECP through December 2019 were considered eligible for the study (n = 357). All patients had five or more ED visits in the past year or two or more inpatient hospitalizations in the past year prior to enrollment. ECP is a high-intensity outpatient intervention intended to reduce avoidable unplanned care such as ED visits and inpatient hospital stays through home visits, chronic/acute disease management, and intensive care coordination. The primary outcomes of interest were events per 100 members per year of ED use with return to home, unplanned inpatient and observational status admissions, and unplanned behavioral health inpatient admission, and cost of care per member per month. Overall total unplanned care encounters were significantly reduced with a difference-in-difference of 320 unplanned care encounters per 100 members per year in the intervention group (p < 0.05). The ECP group showed statistically significant decreases in costs of unplanned ED, unplanned observation admission, and unplanned inpatient behavioral medicine costs, but statistically significant increases in overall pharmacy costs and lab costs. Changes in total costs of care for the ECP group were not statistically different than the control group (p = 0.55). ECP showed significant reduction of unplanned care for MVP patients.

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.

Pediatric Hospitalizations for Ambulatory Sensitive Conditions in Portugal

Pediatric Hospitalizations for Ambulatory Sensitive Conditions in Portugal

What next for COVID Oximetry and virtual ward?

The recent roll-out of COVID Oximetry and virtual ward services across the NHS in England has occurred at a staggering pace. In February 2021, >27 000 high-risk patients with COVID-19 have been treated at home since the first national standard operating procedure was introduced in November 2020 (further information available from authors).1 Observational evidence relating to the effectiveness and value of these local services has started to emerge, with larger national evaluations of the service currently ongoing.2 As services look to become sustainable in the long term and the prevalence of COVID-19 is relatively low, we will soon be presented with an opportunity to decide which elements of these services we wish to amplify and which we should discard. As a result, NHS England is increasingly looking at how it can support automated remote patient monitoring at the patient home through integrated digital platforms for high-prevalence, ambulatory-sensitive conditions such as hypertension, chronic obstructive pulmonary disease (COPD), heart failure, and diabetes. This is moving beyond the usual modes of care delivery such as office-based care for these conditions. This has led to much discussion about whether oximetry and virtual wards should evolve into a single integrated NHS@ home remote patient monitoring service.3 Here we look at whether the enablers achieved through COVID Oximetry @home and virtual wards will be sufficient to overcome some of the historical barriers to introducing telemonitoring services and achieve a coherent, deliverable vision of NHS@home (Figure 1). Figure 1: Historical barriers and current enablers to delivering NHS@home. Source: adapted from Kruse et al. 4 Despite findings from a number of randomised trials,4,5 telemonitoring was not universally adopted within the NHS pre-COVID. Lack of a coherent organising vision, with different stakeholder …

Exploring Health Literacy, Transition Readiness, and Healthcare Utilization in Medicaid Chronically Ill Youth

PurposeYouths with special healthcare needs face challenges transitioning from pediatric to adult health care. Understanding possible mechanisms contributing to poor healthcare transition could improve care. This study explores associations between health literacy (HL), transition readiness, and healthcare utilization. MethodsYouths with special healthcare needs aged 12–18 years were recruited from a Medicaid accountable care organization (2012–2017). Outcome measures included transition readiness (Transition Readiness Assessment Questionnaire), and healthcare utilization (any well-check, hospitalization, emergency department [ED] visit, or ambulatory sensitive condition ED visit). Multivariate regression analyses examined whether HL (adequate vs. inadequate) predicted outcomes, after adjusting for covariates. Models were then created to examine whether the effect of HL on healthcare utilization was mediated by transition readiness. ResultsAmong 417 youths with special healthcare needs, 67.1% reported adequate HL. Relative to inadequate HL, teens with adequate HL had significantly higher average Transition Readiness Assessment Questionnaire-20 scores (β = .34, p < .001). Controlling for covariates, HL was a significant predictor of having an ambulatory sensitive condition ED visit and having any ED visits neared significance. There was a positive transition readiness mediation effect on having an ED visit, with higher transition readiness being associated with higher odds of having any ED visit in the mediation analysis. ConclusionsHL is independently associated with higher transition readiness and lower ambulatory sensitive condition ED use, but pathways of action require further study.

357 Utilizing a Health Information Exchange to Improve Care Transitions After an Emergency Department Visit

Improving care transitions for ambulatory sensitive conditions such as diabetes between the ED and primary care is important to patient safety. Health information exchanges (HIEs) may be useful tools in this process, although data demonstrating this impact is lacking. The primary objective of this study was to assess the feasibility of implementing a tailored care plan in the emergency department Information Exchange (EDIE), a statewide emergency department HIE and care coordination platform endorsed by the American College of Emergency Physicians. We hypothesize that patients who receive this intervention will have decreased ED visits and increased contacts with primary care providers after an ED visit compared to patients who did not receive the intervention. We performed a randomized parallel experimental study with a pre-post design. A total of 260 patients who were attributed to one of four primary care clinics within the University of Washington system, had a diagnosis of diabetes and had at least one ED visit were randomly assigned to the CARE (Coordination and Referral from Emergency) intervention or a control arm. CARE included a tailored care plan in the EDIE which is a care coordination HIE platform that is used in all EDs in Washington and across 22 states. The care plan included primary care clinic information, current diabetes medications, and HgA1c values and was pushed to emergency providers at the time a patient checked in to any ED that utilizes EDIE. Care plans were updated weekly. Measured outcomes included statewide ED visits and primary care clinic contacts within 10-days of an ED visit. These outcomes were compared using “differences in differences” models 12 months pre- and post-intervention. Overall, the number of ED visits decreased significantly in the post-intervention period (mean ratio: 0.75, p=0.002). The decrease was statistically significant in the intervention group (0.66, p=0.003) while the decrease in the control group was non-significant (0.83, p=0.10) over the same period. Similarly, the rate of primary care provider contacts after an ED visit decreased significantly overall (odds ratio: 0.76, p=0.048). In this case the decrease was statistically significantly in the control group (0.68, p=0.018) but not in intervention group (0.86, p=0.45). However, the difference in differences was not significant for either ED visits (p=0.11) or clinic contacts (p=0.37). Results were similar when adjusting for site, sex, age, and English as primary spoken language. Overall implementation of tailored care plans within a HIE care coordination platform is feasible. Patients with diabetes and previous ED visits with a tailored care plan in a statewide care coordination HIE had fewer ED visits after implementation. However, differences in post-period ED visits and clinic contacts were not statistically significant between experimental and control groups.

Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care

ObjectivesTo evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP).SettingIn 2014, National Health Service England signalled a move towards devolution of...

Evaluation of a countywide alternative to QOF, aimed at improving person-centred coordinated care

BackgroundThe Quality Outcomes Framework (QOF) for general practice is one of the largest pay-for-performance schemes in the world. The scheme, however, is sometimes viewed as anachronistic, with recent proposals for a slimmed down QOF. Over the last few years, Somerset have been trialling a system with national implications: 55 GP practices in Somerset established the Somerset Quality Practice Scheme (SPQS) — a de-incentivisation of QOF — with the goal of redirecting resources towards improved Person Centred Coordinated Care (P3C), especially for those with long-term conditions.AimAn evaluation of the SPQS scheme to establish benefits (for example in provision of P3C) or disbenefits (for example in emergency admissions).MethodA longitudinal evaluation from 55 SPQS practices and 17 regional controls. Patient experiences (2363 patients), staff experiences (127 professionals), and organisational data (for SPQS and control practices) were collected. Emergency admission data was analysed for ambulatory-sensitive conditions across Somerset.ResultsDiscretion from QOF resulted in time savings in the majority of practices. Organisational data revealed a significant increase in P3C. Care delivery was improved via stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. Patient and practitioner experiences were similar in SPQS versus control practices. No disbenefits were detected in admissions data.ConclusionThe SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF, enabling participating practices to engage in a number of schemes aimed at improving care for people with LTCs.

Social Risk Adjustment of Quality Measures for Diabetes and Cardiovascular Disease in a Commercially Insured US Population

Patients' social risk factors may be associated with physician group performance on quality measures. To examine the association of social risk with change in physician group performance on diabetes and cardiovascular disease (CVD) quality measures in a commercially insured population. In this cross-sectional study using claims data from 2010 to 2014 from a US national health insurance plan, the performance of 1400 physician groups (physicians billing under the same tax identification number) was estimated. After base adjustments for age and sex, changes in variation across groups and reordering of rankings resulting from additional adjustments for clinical, social, or both clinical and social risk factors were analyzed. In all models, only within-group associations were adjusted to distinguish the association of patients' social risk factors with outcomes while excluding physician groups' distinct characteristics that could also change observed performance. Data analysis was conducted between April and July 2018. Process measures (hemoglobin A1c [HbA1c] testing, low-density lipoprotein cholesterol [LDL-C] testing, and statin use), disease control measures (HbA1c and LDL-C level control), and use-based outcome measures (hospitalizations for ambulatory-sensitive conditions) were calculated with base adjustment (age and sex), clinical adjustment, social risk factor adjustment, and both clinical and social adjustments. Quality variance in physician group performance and changes in rankings following these adjustments were measured. This study identified 1 684 167 enrollees (859 618 [51%] men) aged 18 to 65 years (mean [SD] age, 50 [10.7] years) with diabetes or CVD. Performance rates were high for HbA1c and LDL-C level testing (mean ranged from 79.5% to 87.2%) but lower for statin use (54.7% for diabetes cohort and 44.2% for CVD cohort) and disease control measures (57.9% on LDL-C control for diabetes cohort and 40.0% for CVD cohort). On average, only 8.8% of enrollees with diabetes and 1.0% of enrollees with CVD in a group were hospitalized. The addition of clinical and social risk factors to base adjustment reduced variance across physician groups for most measures (percentage change in SD ranged from -13.9% to 1.6%). Although overall agreement between performance scores with base vs full adjustment was high, there was still substantial reordering for some measures. For example, social risk adjustment resulted in reordering for disease control in the diabetes cohort. Of the 1400 physician groups, 330 (23.6%) had performance rankings for HbA1c control that increased or decreased by at least 10 percentile points after adding social risk factors to age and sex. Both clinical and social risk adjustment affected rankings on hospital admissions. Accounting for social risk may be important to mitigate adverse consequences of performance-based payments for physician groups serving socially vulnerable populations.

Impact of the Southwark and Lambeth Integrated Care Older People’s Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis

ObjectivesTo estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation.DesignObservational study: controlled time series...

International variations in primary care physician consultation time: a systematic review of 67 countries

ObjectiveTo describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes.Design and...

Contested Ownership of Disease and Ambulatory-Sensitive Emergency Department Visits for Type 2 Diabetes

BackgroundApproximately 21 million persons have diabetes and account for 11.9% of all emergency department (ED) visits for a total cost of $14.1 billion. Nonemergent visits for ambulatory-sensitive conditions that could be managed by the primary care provider make up almost one-third of the ED visits. African Americans comprise approximately 30% of South Carolina׳s population but make up approximately 50% of the ED visits for diabetes. The purpose of the research was to explore the experiences of 20 African-American adults with diabetes with ambulatory-sensitive ED use. Research Design and MethodsThe research design for this study is grounded theory with dimensional analysis methods. Following ethics approval and informed consent, interviews were conducted, recorded and transcribed verbatim, and themes were analyzed to form the explanatory framework or matrix for ED use. The framework of context, conditions, processes and consequences provides a key for understanding the themes of the story embedded in the descriptive narratives. ResultsThe contested ownership of diabetes was the overarching perspective—“doing what I got to do,” “it׳s always on mind… wishing not to be a diabetic” and “it׳s a constant burden.” And handling diabetes involved taking decisions “into your hands.” The context of perceived urgency of symptoms included all the reasons that precipitated ED visit—personal experience, primary care access and services and social network support for decisions-influenced ownership of these decisions.

Hospitalizations of adults with intellectual disability in academic medical centers.

Individuals with intellectual disability (ID) represent a small but important group of hospitalized patients who often have complex health care needs. Individuals with ID experience high rates of hospitalization for ambulatory-sensitive conditions and high rates of hospitalizations in general, even when in formal community care systems; however, no research was found on the common reasons for which this population is hospitalized. Academic medical centers often treat the most complex patients, and data from these centers can provide insight into the needs of patient populations with complex needs. The purpose of this study was to analyze descriptive data from the UHC (formerly known as the University Healthsystem Consortium; an alliance of 115 U.S. academic medical centers and 300 of their affiliated hospitals) regarding common reasons for hospitalization, need for intensive care, and common hospitalization outcome measures of length of stay and complications for adult (age ≥ 18) patients with ID. Findings indicate the need for specific attention to the needs of hospitalized patients with ID.

Internações por condições sensíveis à atenção primária à saúde em uma região de saúde paulista, 2008 a 2010

Objective: describe hospital admissions for ambulatory sensitive conditions (ACS) in the Sao Jose do Rio Preto health region, Sao Paulo State, Brazil. Methods. a descriptive study using data from the Unified Health System’s Hospital Admissions Information System, 2008-2010. Results: the ACS coefficient for this health region was around 13.0/1000 inhabitants each year. The five most common diagnoses were heart failure, angina, urinary tract infections, infectious gastroenteritis and cerebrovascular diseases. Circulatory system diseases were the primary diagnosis recorded in 41.5% of these admissions. ACS expenditure was R$ 30,370,691.08, corresponding to 17% of the total costs of hospital admissions in this health region. Conclusion: the occurrence potentially preventable ACS indicates the need for further investigations about possible factors that may be interfering with the organization and outcomes of primary care in the region studied.

Characteristics of physicians and patients who join team-based primary care practices: Evidence from Quebec's Family Medicine Groups

PurposeNew models of delivering primary care are being implemented in various countries. In Quebec, Family Medicine Groups (FMGs) are a team-based approach to enhance access to, and coordination of, care. We examined whether physicians’ and patients’ characteristics predicted their participation in this new model of primary care. MethodsUsing provincial administrative data, we created a population cohort of Quebec's vulnerable patients. We collected data before the advent of FMGs on patients’ demographic characteristics, chronic illnesses and health service use, and their physicians’ demographics, and practice characteristics. Multivariate regression was used to identify key predictors of joining a FMG among both patients and physicians. ResultsPatients who eventually enrolled in a FMG were more likely to be female, reside outside of an urban region, have a lower SES status, have diabetes and congestive heart failure, visit the emergency department for ambulatory sensitive conditions and be hospitalized for any cause. They were also less likely to have hypertension, visit an ambulatory clinic and have a usual provider of care. Physicians who joined a FMG were less likely to be located in urban locations, had fewer years in medical practice, saw more patients in hospital, and had patients with lower morbidity. ConclusionsPhysicians’ practice characteristics and patients’ health status and health care service use were important predictors of joining a FMG. To avoid basing policy decisions on tenuous evidence, policymakers and researchers should account for differential selection into team-based primary health care models.

Getting Back to Basics

The physician–patient relationship is full of enough subtleties and surprises to challenge even the most seasoned clinician. Many high-stakes encounters are a balancing act. How do you tell a young mother that the finding of peritoneal metastases means her cancer is incurable? Assess a request from a patient with chronic pain who may also be drug-seeking? Convince a depressed widower that antidepressants aren’t a “crutch,” but a key to recovery? Or help a patient with recurrent low back pain recognize that what she needs is physical therapy and a solid weight loss plan, not another MRI. Honing the skills to deal with these communication challenges is, for many general internists, a key source of professional satisfaction. Words can injure patients just as surely as an errant scalpel, or heal as effectively as the most potent medication. As with technical procedures, becoming a more effective communicator takes effort, practice, and additional training. Not all of us can become expert communicators, but we all can get better. And a good place to start is with the basics. In this issue of JGIM, Tackett et al. look at the execution of six communication behaviors by 24 academic hospitalists in Baltimore.1 These behaviors, collectively coined “etiquette-based medicine” by Michael Kahn, are so basic they might deserve the label “common courtesy.” But as the study highlights, courtesy on the hospital wards is not so common. Physicians introduced themselves in less than half of all encounters and sat down in less than a third. Asking patients for their perspective on their illness or the hospitalization was vanishingly rare. The authors suggest that use of a simple checklist could allow health care providers “to start every patient interaction with overt displays of respect and humanism.” Other articles this month also touch on the value of the basics. For example, an article by Patel et al. examines readiness for meaningful use of electronic health records (EHRs) among primary care and specialty practices.2 Among the more interesting findings, primary care practices with “basic” EHR functionality almost always met criteria for “core” meaningful use; the same was not true in specialty practices. In a different vein, Chretien and Chretien argue that the country is underprepared to deal with the health problems of returning veterans from Iraq and Afghanistan, and that non-Department of Veterans Affairs (VA) providers will need rapid remediation (“basic training”?) to cope effectively with the influx.3 And a provocative study by Davydow et al. suggests that inadequately treated major depression is a major risk factor for hospitalization for ambulatory-sensitive conditions.4 A Capsule Commentary by JGIM Deputy Editor Matt Bair puts the findings in context.5 It is accepted wisdom in the business world that execution beats strategy six days out of seven. Executing on the basics, and executing well, may be a principle the medical world would do well to adopt.

Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury?

Retrospective cohort with linkage of administrative data sets. To describe the patterns (for example, number of visits by year post-injury) and characteristics of the emergency department (ED) visits (for example, acuity level, timing of visits, reasons for visits) made by persons with traumatic spinal cord injury (TSCI) over a 6-year period following injury. Ontario, Canada. Rates of ED utilization and reasons for ED visits were calculated between the fiscal years 2003-2009. Reasons for visits were categorized by acuity level: potentially preventable visits were defined as visits related to ambulatory sensitive conditions; low acuity and high acuity visits were defined by the Canadian Triage and Acuity Scale. The total number of ED visits for the 6-year period is 4403 (n=1217). Of these visits, 752 (17%) were classified as potentially preventable, 1443 (33%) as low acuity and 2208 (50%) as high acuity. The majority of patients, regardless of acuity level, did not see a primary care practitioner on the day of the ED visit and most visits occurred during the weekday (Mon-Fri 0700-1659 hours). ED use was highest in the first year but remained high over the subsequent years. For potentially preventable visits, the majority of visits were related to urinary tract infections (n=385 visits, 51.2%), followed by pneumonia (n=91, 12.1%). Given the high rates of ED use for low acuity and potentially preventable conditions, these results suggest that the ED is being used as an inappropriate substitute for primary care for individuals with TSCI 50% of the time.

Two Years and Counting

IN LESS THAN 2 YEARS, ALL US CITIZENS AND LEGAL US RESIdents will have health insurance—except individuals who are willing to pay a penalty for not buying insurance. The United States is on the verge of joining the civilized world. Of course, this outcome will occur only if, among other things, the US Supreme Court does not rule that the Patient Protection and Affordable Care Act is unconstitutional, if US and state governments can enact the necessary policies and regulations, and if the health insurance exchanges required to implement the law will work. Whether a proponent or a critic of this law, most will agree with the undeniable fact that a new era in US medicine and US health care begins in less than 2 years. The key question is what potential measures should be monitored to determine both anticipated and unanticipated effects of the new law on the health of the US population. The first measure of the law’s success should be how much preventable mortality that is due to the health care system will be eliminated. Preventable mortality has many causes, ranging from personal behaviors to social determinants of health, to poor inpatient and outpatient care. Ways to assess preventable mortality have been available for many years. It is time to develop a national sampling frame of deaths and to determine, almost on a real-time basis, the proportion of an individual’s death that might have been prevented by better hospital care, better ambulatory care, or better personal behaviors. For example, a death from lung cancer in a patient who smoked could be attributed to smoking behavior, a stroke that occurred in a patient with inadequately controlled hypertension could be ascribed to poor ambulatory care, and an in-hospital death from a central line infection could be attributed to poor hospital care. The goal of health care reform should be to drive the number and proportion of preventable deaths that are under the control of the medical care system (ie, deaths due to poor ambulatory or hospital care) as close to zero as possible. National baseline data regarding the numbers of preventable deaths are necessary to monitor the change in the preventable death rate over time. The second measure of the law’s success should be how many preventable hospitalizations are avoided. The United States has a large number of avoidable hospitalizations from ambulatory-sensitive conditions. The rate of avoidable hospitalization varies across the nation by geographic area (poor neighborhoods have higher rates). Examining the reason that a patient was admitted to the hospital—eg, uncontrolled diabetes or asthma—can help to determine whether the hospital admission could have been avoided with better outpatient care. Thus, the second goal of health care reform should be to drive the avoidable hospitalization rate from ambulatory-sensitive conditions to zero. The third measure of the success of health care reform should be whether it increases to 100% the number of US residents who have access to a system of care. Loosely defined, this means that whether a patient needs emergency care, outpatient care, primary care, tertiary care, or an organ transplant, a coordinated system of care exists to ensure that the patient received the appropriate level of service and was able to access higher levels of medical care if needed. An organization that provides only emergency care without any arrangements for specific follow-up care does not represent a system of care. A health center that provides high-quality outpatient primary care but cannot arrange for subspecialty care or hospital care when needed is not a system of care. If a gynecologist needs to treat a woman with severe depression because she has no access to a mental health professional, she has no system of care. If the physician providing emergency care is not capable of reducing a complicated fracture but must attempt the reduction because no orthopedic surgeon is available, the patient with the fracture does not have a system of care. This loose definition of a system of care does not require that a patient have a primary care gatekeeper or restricted access to a specialist. Rather, it requires that patients have a reasonable chance of receiving the level of care they need in a reasonably timely manner. Systems of care range from an accountable care organization to a health maintenance organization to the Veterans Affairs, but systems must be sufficiently organized, so patients with serious problems are not left to fend for themselves. The fourth measure that can be used to monitor the health care reform act should be the cost of care divided by the num-

Hospital-level variation in the percentage of admissions originating in the emergency department

PurposeWell over half of all US hospital patients are now admitted directly through the emergency department (ED) rather than scheduled through the admissions department by a referring member of the medical staff. This study sought to understand hospital-level variation in the percentage of admissions originating in the ED. Basic ProceduresThis was a retrospective, cross-sectional analysis of 5 748 375 ED visits and 2 265 478 inpatient discharge occurring in 192 short-term acute Florida hospitals in calendar year 2005. Main FindingsHospitals with increasing percentages of patients admitted through the ED are smaller in scale with fewer admissions, beds, and smaller medical staffs but admit a higher percentage of their ED visits to the hospital. Patients in these hospitals are increasingly Hispanic, older, Medicare insured, and likely to represent a preventable ambulatory sensitive condition. ConclusionsThe increasing rate of admissions from the ED department is a national trend, but there is substantial variation at the hospital level. In Florida, measures of hospital scale and an older population with some limitations in access to, or the quality of, primary care are the factors influencing hospital-level variation. Factors implicated in increased ED use such as ED visit acuity, lack of insurance, and race are not important contributory variables. The process of admission and, particularly, the role of the organized medical staff in this process are evolving, and the consequences of these changes require further research.