Ambulatory Sensitive Hospitalizations Research Articles

Hauora Māori – Māori health: a right to equal outcomes in primary care

BackgroundFor more than a century, Māori have experienced poorer health than non-Māori. In 2019 an independent Tribunal found the Government had breached Te Tiriti o Waitangi by “failing to design and administer the current primary health care system to actively address persistent Māori health inequities”. Many Māori (44%) have unmet needs for primary care. Seven models of primary care were identified by the funders and the research team, including Māori-owned practices. We hypothesised patient health outcomes for Māori would differ between models of care.MethodsCross-sectional primary care data were analysed at 30 September 2018. National datasets were linked to general practices at patient level, to measure associations between practice characteristics and patient health outcomes. Primary outcomes: polypharmacy (≥ 55 years), HbA1c testing, child immunisations, ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Regressions include only Māori patients, across all models of care.ResultsA total of 660,752 Māori patients were enrolled in 924 practices with 124,854 in 65 Māori-owned practices.Māori practices had: no significant association with HbA1c testing, ambulatory sensitive hospitalisations or ED attendances, and a significant association with lower polypharmacy (3.7% points) and lower childhood immunisations (13.4% points).Māori practices had higher rates of cervical smear and cardiovascular risk assessment, lower rates of HbA1c tests, and more nurse (46%) and doctor (8%) time (FTE) with patients.The average Māori practice had 52% Māori patients compared to 12% across all practices. Māori practices enrolled a higher percentage of children and young people, five times more patients in high deprivation areas, and patients with more multimorbidity.More Māori patients lived rurally (21.5% vs 15%), with a greater distance to the nearest ED. Māori patients were more likely to be dispensed antibiotics or tramadol.ConclusionsMāori practices are an expression of autonomy in the face of enduring health system failure. Apart from lower immunisation rates, health outcomes were not different from other models of care, despite patients having higher health risk profiles. Across all models, primary care need was unmet for many Māori, despite increased clinical input. Funding must support under-resourced Māori practices and ensure accountability for the health outcomes of Māori patients in all models of general practice.

Is there equity of patient health outcomes across models of general practice in Aotearoa New Zealand? A national cross-sectional study

BackgroundPrimary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care.MethodsWe conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances.Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes.Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response.ResultsThe study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices.There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes.ConclusionsModel-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care.

Estimating the economic costs of Indigenous health inequities in New Zealand: a retrospective cohort analysis

ObjectivesDespite significant international interest in the economic impacts of health inequities, few studies have quantified the costs associated with unfair and preventable ethnic/racial health inequities. This Indigenous-led study is the...

Understanding geographical variations in health system performance: a population-based study on preventable childhood hospitalisations

ObjectiveTo investigate interdistrict variations in childhood ambulatory sensitive hospitalisation (ASH) over the years.DesignObservational population-based study over 2008–2018 using the Primary Health Organisation Enrolment Collection (PHO) and the National Minimum Dataset...

179Selecting health need indicators for spatial equity analysis of primary health care in New Zealand

Abstract Background Populations with high needs often have poor health care access. Defining need is challenging, with no agreed-upon indicator of health need for primary care based spatial equity research in New Zealand. We examined seven potential indicators and tested for evidence of the Inverse Care Law in the Waikato region. Methods Indicators were identified through a systematic literature review and scored according to ten selection criteria. Indicators were mapped and analysed using GIS. Spearman’s correlations were calculated between indicators, and clusters of high need identified through spatial autocorrelation. The impact of incorporating indicator-based-weightings into an accessibility model was tested using ANOVA and Spearman’s correlations. GP service spatial equity was assessed by comparing clusters of access and need, and quantified through the Gini coefficient. Results While smoking rates met the most selection criteria, ambulatory sensitive hospitalisation (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and Gini coefficient of 0.281 suggests that services are not equitably distributed. Conclusions ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. High need clusters vary spatially according to the indicator used. Key messages GIS techniques can identify ‘hot-spots’ of need, but these can be masked in accessibility models. Indicators should be carefully selected according to the research question.

GP- and practice-related variation in ambulatory sensitive hospitalisations of older primary care patients

BackgroundReducing ambulatory sensitive hospitalisations (ASHs) is a strategy to control spending on hospital care and to improve quality of primary health care. This research investigated whether ASH rates in older people varied by GP and practice characteristics.MethodsWe identified ASHs from the national dataset of hospital events for 3755 community-dwelling participants aged 75+ enrolled in a cluster randomised controlled trial involving 60 randomly selected general practices in three regions in New Zealand. Poisson mixed models of 36-month ASH rates were fitted for the entire sample, for complex participants, and non-complex participants. We examined variation in ASH rates according to GP- and practice-level characteristics after adjusting for patient-level predictors of ASH.ResultsLower rates of ASHs were observed in female GPs (IRR 0.83, CI 0.71 to 0.98). In non-complex participants, but not complex participants, practices in more deprived areas had lower ASH rates (4% lower per deprivation decile higher, IRR 0.96, CI 0.92 to 1.00), whereas main urban centre practices had higher rates (IRR 1.84, CI 1.15 to 2.96). Variance explained by these significant factors was small (0.4% of total variance for GP sex, 0.2% for deprivation, and 0.5% for area type). None of the modifiable practice-level characteristics such as home visiting and systematically contacting patients were significantly associated with ASH rates.ConclusionsOnly a few GP and non-modifiable practice characteristics were associated with variation in ASH rates in 60 New Zealand practices interested in a trial about care of older people. Where there were significant associations, the contribution to overall variance was minimal. It also remains unclear whether lower ASH rates in older people represents underservicing or less overuse of hospital services, particularly for the relatively well patient attending practices in less central, more disadvantaged communities. Thus, reducing ASHs through primary care redesign for older people should be approached carefully.Trial registrationAustralian and New Zealand Clinical Trials Register ACTRN12609000648224.

Selecting Health Need Indicators for Spatial Equity Analysis in the New Zealand Primary Care Context.

To examine potential indicators of health need for primary care in spatial equity research, and evidence of the Inverse Care Law in the Waikato region of New Zealand. A cross-sectional analysis of 7 health need indicators (ambulatory sensitive hospitalizations; cancer rate; mortality rate; New Zealand index of multiple deprivation-health domain; age; New Zealand index of deprivation; smoking rate) that were identified through a systematic review was carried out. Values of indicators were mapped and analyzed using geographic information systems (GIS). Spearman's correlations were calculated between indicators, and clusters of high need were identified through spatial autocorrelation. The impact of incorporating indicator-based weightings into an accessibility model was tested using analysis of variance and Spearman's correlations. General practice service spatial equity was assessed by comparing clusters of high access versus need, and quantified through the Gini coefficient. Ambulatory sensitive hospitalization (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and a Gini coefficient of 0.281 suggest that services are not equitably distributed. ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. Area-level socioeconomic deprivation measures incorporate some social determinants of health, and they have potential for wider use. High need clusters vary spatially according to the indicator used. GIS techniques can identify "hot-spots" of need, but these can be masked in accessibility models.

Area-level deprivation, childhood dental ambulatory sensitive hospitalizations and community water fluoridation: evidence from New Zealand.

We examined the association between area-level deprivation and dental ambulatory sensitive hospitalizations (ASH) and considered the moderating effect of community water fluoridation (CWF). The hypothesis was that higher levels of deprivation are associated with higher dental ASH rates and that CWF will moderate this association such that children living in the most deprived areas have greater health gain from CWF. Dental ASH conditions (dental caries and diseases of pulp/periapical tissues), age, gender and home address identifier (meshblock) were extracted from pooled cross-sectional data (Q3, 2011 to Q2, 2017) on children aged 0-4 and 5-12 years from the National Minimum Dataset, New Zealand (NZ) Ministry of Health. CWF was obtained for 2011 and 2016 from the NZ Institute of Environmental Science and Research. Dental ASH rates for children aged 0-4 and 5-12 years (/1000) were calculated for census area units (CAUs). Multilevel negative binomial models investigated associations between area-level deprivation, dental ASH rate and moderation by CWF status. Relative to CWF (2011 and 2016), no CWF (2011 and 2016) was associated with increased dental ASH rates in children aged 0-4 [incidence rate ratio (IRR) = 1.171 (95% confidence interval 1.064, 1.288)] and aged 5-12 years [IRR = 1.181 (1.084, 1.286)]. An interaction between area-level deprivation and CWF showed that the association between CWF and dental ASH rates was greatest within the most deprived quintile of children aged 0-4 years [IRR = 1.316 (1.052, 1.645)]. CWF was associated with a reduced dental ASH rate for children aged 0-4 and 5-12 years. Children living in the most deprived areas showed the greatest effect of CWF on dental ASH rates, indicating that the greater health gain from CWF occurred for those with the highest socio-economic disadvantage. Variation in CWF contributes to structural inequities in oral-health outcomes for children.

Paediatric ambulatory care sensitive hospitalisation and Italian deprivation index: retrospective multilevel analysis of administrative data from 2008 to 2018 in the Abruzzo Region (Southern Italy).

to estimate and analyse the trend of paediatric hospitalisations for Ambulatory Care Sensitive Conditions (ACSCs) from 2008 to 2018 in a region of southern Italy and to assess the association with the socio-economic deprivation index (DI). retrospective observational study. ACSC hospitalisations in children (<=18 years) were identified. Discharges for ACSC of the Abruzzo Region from 2008 to 2018 were selected and the deprivation index of the municipality of residence was assigned to the hospital discharge record where the patient's residence was reported. the rate of paediatric preventable admissions (PPHs) related to ACSC, standardized by age and gender with the direct method, was calculated for the years of observation. The average annual percentage change (AAPC) was calculated with a trend analysis. In addition, the odds ratios (ORs) of hospitalisation for ACSC were calculated using a hierarchical logistic regression model. 252,513 hospitalisations were examined, of which 16,264 (6.4%) attributable to ACSC. During the study period, the hospitalisation rate decreased from 8.59 per 1,000 to 6.12 per 1,000 residents, with an AAPC of -3.7, which was statistically significant (p<0.05). Furthermore, an association was highlighted between hospitalisations related to ACSC and the deprivation of the municipality of residence. Using as a comparison people residing in the municipalities belonging to the first quintile, the least deprived, the strength of the association between PPHs and DI increased from the third quintile (OR 1.13; CI95% 1.02-1.24) up to the fifth quintile, most deprived (OR 1.14; CI95% 1.01-1.30). paediatric patients residing in Abruzzo have a risk of undergoing a preventable hospitalisation associated with an ACSC which depends on the deprivation index of the municipality of residence. Although it is difficult to evaluate the mechanisms involved in the relationship between economic deprivation and hospitalisation, DI can be useful to identify the areas which are most at risk on which to prioritize public health interventions.

Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians.

Visual Abstract.Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians Visual Abstract. Envisioning a Better U.S. Health Care System for All: A...

Difference in access to health care for newly arrived refugees in Germany: a natural quasi-experiment

Abstract Background Providing quantitative evidence on structural access barriers to health care for newly arrived refugees constitutes a challenge due to a lack of suitable data. The coexistence of two different local access models in Germany allows for a comparative analysis of the association between access policies and realized access. Our study compares these two models to establish whether they lead to differences in access to care among refugees. Methods Municipalities in Germany’s largest federal state of North Rhine-Westphalia (NRW) have implemented different access models to which refugees are quasi-randomly assigned. We recruited 6 municipalities of which 3 decided to implement the health care voucher (HcV) model and 3 the electronic health card model (eHC) in a natural quasi-experimental study design. Analyses were based on claims data collected from the welfare offices or the statutory health insurance. We compared standardized incidence rates (SIR) based on 3 indicators: emergency service, ambulatory sensitive hospitalization and use of specialized care. Results We included data on health care use of all recently assigned refugees in the 6 municipalities over a period of 7 quarters (2016/17). The average quarterly sample size is n = 9,077 which corresponds to 6.5% of the population of recently assigned refugees in NRW at that time. We find differences in realized access between the models. For emergency care, the SIR differ significantly between municipalities using the HcV model (SIR:1.88; 95%-CI: 1.62-2.18) and eHC model (SIR:1.33; 95%-CI: 1.14-1.55). Conclusions Local decisions regarding the organization of access to health care are associated with differences in realized access to health care of refugees in NRW. The implementation of the eHC model may contribute to a decrease of emergency service. Further analyses should attempt to reduce a possible (self-)selection bias of municipalities which might have led to an underestimation of the difference between models. Key messages The organization of health care for newly arrived refugees on the local level is decisive for their access to care. Local policy makers may use their scope for action to remove access barriers for newly arrived refugees.

The impact of a community pharmacy service on patients' medication adherence and ambulatory sensitive hospitalizations.

In July 2012 a nationwide community pharmacy-based service was launched in New Zealand. The Long Term Conditions (LTC) service was introduced to help patients with chronic medical conditions, who have difficulties adhering to their medication regimens, improve their adherence. As part of the service pharmacists provide a variety of interventions including: patient education, medication reconciliation, medication synchronization, as well as preparing adherence support aids such as blister packs, sending reminders, and providing tailored dispensing frequencies. Seven years after its introduction scant data are available measuring the impact of the service on patients' health outcomes. To examine the impact of LTC on patients' medication adherence and ambulatory sensitive hospitalizations. This was a retrospective matched-cohort study using routinely collected health data. The population studied were individuals enrolled in LTC between July 2013 and December 2014 and a control group of propensity score matched individuals who never received the service. Outcomes were assessed during and after completion of the intervention. Sensitivity analysis was also undertaken whereby only those who completed the intervention and their controls were used in the analysis. The matched cohort consisted of 51,138 individuals in the intervention and 51,138 in the control. Enrolment in LTC was associated with greater medication adherence, with individuals in the intervention group having 2.99 (95% CI: 2.79-3.20) greater odds of being adherent 12 months after the start of the study period, compared to the control group. These patients also had 1.86 (95% CI: 1.78-1.96) greater odds of having an ambulatory sensitive hospitalization 12 months after the start of the study period, compared to the control group. This study found that enrolment in LTC achieved one of the service's primary aims of improved medication adherence. However, enrolment in the service also appears to be associated with greater ambulatory sensitive hospitalizations, which is an unexpected finding. Further research is needed to better understand this.

Epidemiology of multimorbidity in New Zealand: a cross-sectional study using national-level hospital and pharmaceutical data

ObjectivesTo describe the prevalence of multimorbidity (presence of two or more long-term health conditions) in the New Zealand (NZ) population, and compare risk of health outcomes by multimorbidity status.DesignCross-sectional analysis...

Are there differences within pre-school aged Pacific peoples’ hospital presentations with preventable conditions?

Aim. To describe the top five causes of preventable health conditions among Pacific children (Cook Island, Fijian, Niuean, Samoan, Tongan, Tokelauan) aged 0-4 years living in New Zealand (NZ), and to make comparisons of these rates with NZ’s population who were of neither Maori nor Pacific ethnicity (NMNP). &#x0D; Method. This study is a retrospective analysis of preschool Ambulatory Sensitive Hospitalisations (ASH) by ethnicity. The data, from 2010 to 2014, was extracted from The National Minimum Dataset.&#x0D; Results. The top five preventable health conditions among Pacific under 5’s were asthma and wheeze, gastroenteritis, dental, skin infections and pneumonia. Rates for all Pacific children with any of the ASH conditions were four to five times higher among Pacific, than among NMNP, from 2000 to 2014. Pacific children were also significantly more likely to present with bronchiectasis and rheumatic fever or rheumatic heart disease (RR 25.7 and 26.4 respectively).&#x0D; Conclusion. Pacific children aged 0-4 years are more likely to be exposed to health conditions that are considered preventable . The most common preventable health conditions experienced by Pacific children were asthma and wheeze, gastroenteritis, dental, skin infections and pneumonia. These findings highlight the importance of investing in effective prevention strategies to further investigate and address the underlying causes of these conditions.

Training needs analysis - The essential first step for continuing professional development design.

Nursing services are expected to be dynamic in response to changing health care needs. This expectation requires the purposeful and effective development of nursing workforce capability through continuing professional development (CPD). An evidence based approach to training needs analysis (TNA) is a highly recommended yet often missing first step in designing a CPD strategy for service improvement. This study used the Hicks-Hennessey questionnaire, a validated TNA tool to inform regional educational commissioning to meet the aims of a community social sector trial (SST) project. The SST objectives were to improve access to appropriate primary care through reducing Ambulatory Sensitive Hospitalisations and Emergency Department attendances among people aged 0-74 years. Using a descriptive research approach with the Hicks-Hennessey questionnaire, ten priority training needs were identified by regional primary health care nurses to inform the design of a purposeful educational response and hence support an enhanced model of care.

Measuring and managing health system performance: An update from New Zealand

In July 2016, New Zealand introduced a new approach to measuring and monitoring health system performance. This ‘Systems Level Measure Framework’ (SLMF) has evolved from the Integrated Performance and Incentive Framework (IPIF) previously reported in this journal. The SLMF is designed to stimulate a ‘whole of system’ approach that requires inter-organisational collaboration. Local ‘Alliances’ between government and non-government health sector organisations are responsible for planning and achieving improved health system outcomes such as reducing ambulatory sensitive hospitalisation for young children, and reducing acute hospital bed days. It marks a shift from the previous regime of output and process targets, and from a pay-for-performance approach to primary care. Some elements of the earlier IPIF proposal, such as general practice quality measures, and tiered levels of performance, were not included in the SLM framework. The focus on health system outcomes demonstrates policy commitment to effective integration of health services. However, there remain considerable challenges to successful implementation. An outcomes framework makes it challenging to attribute changes in outcomes to organisational and collaborative strategies. At the local level, the strength and functioning of collaborative relationships between organisations vary considerably. The extent and pace of change may also be constrained by existing funding arrangements in the health system.

Better, Sooner, More Convenient? The reality of pursuing greater integration between primary and secondary healthcare providers in New Zealand.

Objectives:This article focuses on the results of evaluations of two business plans developed in response to a policy initiative which aimed to achieve greater integration between primary and secondary health providers in New Zealand. We employ the Consolidated Framework for Implementation Research to inform our analysis. The Better, Sooner, More Convenient policy programme involved the development of business plans and, within each business plan, a range of areas of focus and associated work-streams.Methods:The evaluations employed a mixed method multi-level case study design, involving qualitative face-to-face interviews with front-line staff, clinicians and management in two districts, one in the North Island and the other in the South Island, and an analysis of routine data tracked ambulatory sensitive hospitalisations and emergency department presentations. Two postal surveys were conducted, one focussing on the patient care experiences of integration and care co-ordination and the second focussing on the perspectives of health professionals in primary and secondary settings in both districts.Results:Both evaluations revealed non-significant changes in ambulatory sensitive hospitalisations and emergency department presentation rates and slow uneven progress with areas of focus and their associated work-streams. Our evaluations revealed a range of implementation issues, the barriers and facilitators to greater integration of healthcare services and the implications for those who were responsible for putting policy into practice.Conclusion:The business plans were shown to be overly ambitious and compromised by the size and scope of the business plans; dysfunctional governance arrangements and associated accountability issues; organisational inability to implement change quickly with appropriate and timely funding support; an absence of organisational structural change allowing parity with the policy objectives; barriers that were encountered because of inadequate attention to organisational culture; competing additional areas of focus within the same timeframe; and consequent overloading of front-line staff which led to workload stress, fatigue and disillusionment. Where success was achieved, this largely hinged on the enthusiasm of a small pool of front-line workers and their initial buy-into the idea of integrated care.

Measuring doctor appointment availability in Northland general practice.

INTRODUCTION Primary care access is associated with improved patient outcomes. Availability of appointments in general practice is one measure of access. Northland's demographics and high ambulatory sensitive hospitalisation rates may indicate constrained appointment availability. Our study aims were to determine appointment availability and establish the feasibility of measuring appointment availability through an automated process. METHODS An automated electronic query was created, run through a third party software programme that interrogated Northland general practice patient management systems. The time to third next available appointment (TNAA) was calculated for each general practitioner (GP) and a mean calculated for each practice and across the region. A research assistant telephone request for an urgent GP appointment captured the time to the urgent appointment and type of urgent appointment used to fit patients in. Regression analysis was used to determine the relationships between deprivation, patients per GP, and the use of walk-in clinics. RESULTS The mean TNAA was 2.5 days. 12% of practices offered walk-in clinics. There was a significant relationship between TNAA and increasing number of walk-in clinics. CONCLUSION The TNAA of 2.5 days indicates the possibility that routine appointments are constrained in Northland. However, TNAA may not give a reliable measure of urgent appointment availability and the measure needs to be interpreted by taking into account practice characteristics. Walk-in clinics, although increasing the availability of urgent appointments, may lead to more pressure on routine appointments. Using an electronic query is a feasible way to measure routine GP appointment availability.

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...

Primary health care access and ambulatory sensitive hospitalizations in New Zealand.

Ambulatory sensitive hospitalizations (ASH) are those thought to be preventable by timely and effective primary health care. Better access to primary health care has been associated with lower ASH rates. Funding increases to primary health care in New Zealand beginning in 2001 led to an improvement in access. Analysis of hospitalizations to all New Zealand public hospitals revealed that, for most age groups, ASH rates did not show long-term reductions from 2001 to 2009, while socioeconomic differences in ASH rates widened across this period. We conclude that increasing funding and access to primary health care will not, by itself, reduce ASH rates.