Hospitalizations For Ambulatory Care Sensitive Conditions Research Articles

Medicaid Expansion Associated With Reductions In Preventable Hospitalizations.

Hospitalizations for ambulatory care-sensitive conditions indicate barriers to care outside of inpatient settings. We found that Medicaid expansions under the Affordable Care Act were associated with meaningful reductions in these hospitalizations, which suggests the potential of Medicaid expansions to reduce the need for preventable hospitalizations in vulnerable populations and produce cost savings for the US health care system.

Interrupted time series analyses on the effect on integrated care among the older population

Abstract Background Current health and social care systems in most European countries, are highly fragmented into specialist services, and poorly designed to provide health and social care for patients with multiple health problems and social needs. As some groups of patients might have greater difficulties navigating in a fragmented and divided system than others, current system also risks increasing inequalities in access and use of health and social care services. The aim of this study is to investigate if a comprehensive integrated care system perform better than ‘standard care’ in regards to emergency department visits, hospitalization for ambulatory care sensitive conditions (ACSC), costs and re-admissions as well as increase equity in health care among older people. Methods This study is an intervention study based on a comparative interrupted time series design comparing data from Norrtälje, where an integrated care system was implemented in 2006, with other areas of Stockholm county with a standard care system. The time series consists of register data from 2000-2015, obtained from the Stockholm County Council’s administrative database of healthcare utilization and population data on socio-demographic characteristics from national registers. Preliminary results The preliminary results based on data from 2000-2011 suggest that the introduction of an integrated care system in Norrtälje did not affect the rate of hospitalization for ACSC, costs or rates of emergency department visits. When stratifying on income group we saw that the lowest income group did improve in some of the outcomes. Conclusions The integrated care system in Norrtälje seems to have no significant effect on the outcome measures included. Whether socioeconomic inequity was affected is still to be investigated further. Key messages In this study we used interrupted time series to investigate organisational changes in the health care sector. Introducing integrated care in Norrtälje seems to have little effect on register based outcome measures.

Preventable hospitalizations from ambulatory care sensitive conditions in nursing homes: evidence from Switzerland

ObjectivesReducing nursing home hospitalizations for ambulatory care sensitive conditions (ACSC) has been identified as an opportunity to improve patient well-being and reduce costs. The aim of this study was to identify number of hospitalizations for ACSCs for nursing home residents in a Swiss national sample, examine demographic characteristics of nursing home hospitalizations due to ACSCs, and calculate hospital expenses from these hospitalizations.MethodsUsing merged hospital administrative data with payment data based on diagnosis-related groups (DRGs) for the year 2013, we descriptively examined nursing home residents who were 65 years of age or older and were admitted to an acute care hospital.ResultsApproximately 42% of all nursing home admissions were due to ACSCs. Payments to Swiss hospitals for ACSCs can be estimated at between 89 and 105 million Swiss francs in 2013.ConclusionsA sizable share of hospitalizations for nursing home residents is for ACSCs, and the associated costs are substantial. Programs and policies designed to reduce these potentially avoidable hospitalizations from the nursing home setting could lead to an increased patient well-being and lower costs.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease

A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed. To determine the association of mental health disorders with health care costs among people with chronic diseases. This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018. Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder). Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions. Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001). This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.

Primary health care strategy and its impact on avoidable hospitalizations for ambulatory care-sensitive conditions, Paraguay, 2000-2017Estratégia de atenção primária à saúde e seu impacto nas internações hospitalares evitáveis por causas sensíveis à atenção ambulatorial, Paraguai, 2000-2017

RESUMENObjetivo.Explorar la influencia que ha tenido la implementación y fortalecimiento de la estrategia de atención primaria (APS) sobre las hospitalizaciones por condiciones sensibles al cuidado ambulatorio (HCSCA).Métodos.Estudio observacional descriptivo y transversal, que consideró datos correspondientes a los registros de internaciones de hospitales públicos de todo el país en el período 2000-2017. Se considera el año 2009 como punto de inicio de la estrategia de APS. Para definir los diagnósticos de las HCSCA se utilizaron los propuestos por la Organización Panamericana de la Salud/Organización Mundial de la Salud. Se realizó el análisis de su comportamiento considerando dos etapas: 2000-2008 y 2009-2017.Resultados.Las HCSCA mostraron una tendencia a la disminución, se halló una diferencia de 6,75% entre los años finales de cada etapa. La disminución fue mayor en la medida que se amplió la cobertura de APS. Las principales causas de HCSCA fueron la neumonía y la enfermedad diarreica aguda. Las internaciones por enfermedades crónicas disminuyeron en su mayoría: por el contrario, los ingresos por enfermedades infecciosas aumentaron.Conclusiones.La cobertura y acceso poblacional con unidades de salud familiar puede limitar el impacto de la APS en las HCSCA. Se verifica una disminución de las HCSCA luego de la implementación de la APS en Paraguay. Las internaciones por enfermedades crónicas muestran mejor resultado que las internaciones por enfermedades infecciosas.

Education level and hospitalization for ambulatory care sensitive conditions: an education approach is required.

Studies in several different countries and settings suggest that ambulatory care-sensitive conditions (ACSCs)-related hospitalizations could be associated more with socioeconomic variables than with the quality of primary healthcare services. The aim of the present study was to analyze the potential links between education levels or other social determinants and ACSC-related hospitalization rates. We analyzed a total of 467 504 records of ordinary discharges after acute hospitalization in 2015-16 for patients 20-74 years old residing in the Veneto Region. We calculated the prevention quality indicators (PQIs) developed by the Agency for Healthcare Research and Quality. Rate ratios (RRs) and 95% confidence intervals (95% CIs) were estimated with a set of Poisson regressions to measure the relative risk by sociodemographic level. Hospitalizations for ACSCs accounted for 3.9% of all hospital admissions (18 436 discharges), and the crude hospitalization rate for ACSCs among 20- to 74-year-olds was 26.6 per 10 000 inhabitants (95% CI, 25.8-27.4). For all conditions, we found a significant association with formal education. In the case of the overall composite PQI#90, e.g. poorly educated people (primary school or no schooling) were at significantly higher risk of hospitalization for ACSCs than the better educated (RR, 4.50; 95% CI, 4.13-4.91). Currently available administrative data regarding ACSCs may be used effectively for reveal equity issues in the provision of health care. Our results indicate that an educational approach inside Primary Health Care could address the extra risk for preventable healthcare demands associated with poorly educated patients.

A Spatial Analysis of Preventable Hospitalization for Ambulatory Care Sensitive Conditions and Regional Characteristics in South Korea.

Hospitalization rates for ambulatory care sensitive conditions (ACSCs) can indicate the accessibility of a community's primary care. We examined regional variation in ACSC hospitalization rates and identified associated factors. ACSC hospitalization rates in the 232 districts in 2013 ranged from 4.08 to 101.53 per 1000 adults. Spatial analysis showed that none of the 24 highest rate districts were located near Seoul, whereas 80% of the 45 lowest rate districts were, suggesting health care inequality between people living near Seoul and in other areas. Regression analysis showed significantly higher ACSC hospitalization rates in districts with higher elderly (β = 0.94) and low-income populations (β = 2.25), more remote areas (β = 0.29), and more hospital beds (β = 0.03). The number of primary care clinics was negatively associated with ACSC hospitalization (β = -1.37). For these variables, geographically weighted regression analysis provided local regression coefficients, useful for developing region-specific strategies to reduce ACSC hospitalization.

Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration.

The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization. To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs). Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects. A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module. Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims. Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs. Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.

Variations in VA and Medicare Use Among Veterans With Diabetes: Impacts on Ambulatory Care Sensitive Conditions Hospitalizations for 2008, 2009, and 2010.

VA and Medicare use among older Veterans has been considered fragmented care, however, it may represent access to needed care. The population studied were Veterans with diabetes, age 66 years and older, dually enrolled in VA and Medicare. We conducted a dynamic retrospective cohort study with 2008, 2009, and 2010 as the outcome years (Ambulatory Care Sensitive Conditions Hospitalization (ACSC-H) or not). We analyzed administrative data to identify comorbidities; ambulatory care utilization to identify variations in use before hospitalization. We linked 2007 primary care (PC) survey data to assess if organizational factors were associated with ACSC-H. We identified ACSC-Hs using a validated definition. We categorized VA/Medicare use as: single system; dual system: supplemental specialty care use; or primary care use. Using hierarchical logistic regression models, we tested for associations between VA/Medicare use, organizational characteristics, and ACSC-H controlling for patient-level, organizational-level, and area-level characteristics. Our analytic population was comprised of 210,726 Medicare-eligible Veterans; more than one quarter had an ACSC-H. We found that single system users had higher odds of ACSC-H compared with dual system specialty supplemental care use (odds ratio, 1.14; 95% confidence interval, 1.09-1.20), and no significant difference between dual-system users. Veterans obtaining care at sites where PC leaders reported greater autonomy (eg, authority over personnel issues) had lower odds of ACSC-H (odds ratio, 0.74; 95% confidence interval, 0.59-0.92). Our findings suggest that earlier assumptions about VA/Medicare use should be weighed against the possibility that neither VA nor Medicare may address complex Veterans' health needs. Greater PC leader autonomy may allow for tailoring of care to match local clinical contexts.

Medicaid Expansion and Hospitalization for Ambulatory Care-Sensitive Conditions Among Nonelderly Adults With Diabetes.

Among nonelderly adults with diabetes, we compared hospitalizations for ambulatory care-sensitive conditions from 2013 (pre-Medicaid expansion) and 2014 (post-Medicaid expansion) for 13 expansion and 4 nonexpansion states using State Inpatient Databases. Medicaid expansion was associated with decreases in proportions of hospitalizations for chronic conditions (difference between 2014 and 2013 -0.17 percentage points in expansion and 0.37 in nonexpansion states, P = .04), specifically diabetes short-term complications (difference between 2014 and 2013 -0.05 percentage points in expansion and 0.21 in nonexpansion states, P = .04). Increased access to care through Medicaid expansion may improve disease management in nonelderly adults with diabetes.

Ambulatory care sensitive conditions hospitalization for emergencies rates in Colombia.

ABSTRACTOBJECTIVE To analyze the emergency hospitalizations trend for ambulatory care sensitive conditions between 2011 and 2015 in a health insureance company of the Colombian Social Security General System.METHODS A log-linear analysis based on age-adjusted hospitalization rates for ambulatory care sensitive conditions in the Entidad Promotora de Salud Sanitas was used to estimate the annual percentage change in these rates and to identify joinponts of the rates. Data was collected from administrative sources.RESULTS There were 38,530 hospitalizations for ambulatory care sensitive conditions in 26,501 Entidad Promotora de Salud Sanitas enrollees, with a significant decrease in hospitalization rates. The annual percentage change estimated for the period was -9.5% with no significant joinpoints throughout the time interval.CONCLUSIONS A significant reduction in hospital admissions due to ambulatory care sensitive conditions in Entidad Promotora de Salud Sanitas enrollees were reported for the last five years in this study.

Impact of Cumulative Corticosteroid Dosage on Preventable Hospitalization among Taiwanese Patients with Ankylosing Spondylitis and Inflammatory Bowel Disease.

Background: Corticosteroids are commonly prescribed for autoimmune conditions, but their impact on preventable hospitalization rates is unclear. This study sought to investigate the effect of corticosteroid use on hospitalization for ambulatory care sensitive conditions among Taiwanese patients with ankylosing spondylitis (AS) or inflammatory bowel disease (IBD). Methods: This was a retrospective cohort study using adults in the Taiwan National Health Insurance Research database receiving a new diagnosis of AS (n = 40,747) or IBD (n = 4290) between January 2002 and June 2013. Our main outcome measure was odds of preventable hospitalization for eight ambulatory care-sensitive conditions defined by the Agency for Healthcare Research and Quality. Results: In the first quarter (three months) following diagnosis, corticosteroid usage was common among patients with AS and IBD (18.5% and 30%, respectively). For every 100 mg increase in corticosteroid dose per quarter, adjusted odds of preventable hospitalization in the following quarter increased by 5.5% for patients with AS (aOR = 1.055, 95% CI 1.037–1.074) and 6.4% for those with IBD (aOR = 1.064, 95% CI 1.046–1.082). Conclusions: Relatively low doses of corticosteroids significantly increase AS and IBD patients’ short-term odds of hospitalization for ambulatory care-sensitive conditions. As recommended by current clinical guidelines, physicians should use corticosteroids sparingly in these populations, and prioritize initiation/escalation of disease-modifying anti-rheumatic drugs for long-term management. If corticosteroids cannot be avoided, patients may require monitoring and/or prophylaxis for corticosteroid-associated comorbidities (e.g., diabetes) which can result in preventable hospitalizations.

Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment.

Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians' performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization. To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers' performance. Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers' performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data. Safety-net and non-safety-net clinics. Community-dwelling Medicare beneficiaries contributing 38,616person-years from 2006 to 2013. Acute and chronic ACSC hospitalizations. After adjusting for clinical comorbidities, Alzheimer's/dementia (IRR 1.30, 95% CI 1.02-1.65), difficulty with 3-6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05-1.94), difficulty with 1-2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26-1.90), and 3-6 IADLs (IRR 1.90, 95% CI 1.49-2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03-1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04-1.69), being unmarried (IRR 1.18, 95% CI 1.01-1.36), difficulty with 1-2 IADLs (IRR 1.30, 95% CI 1.05-1.60), and 3-6 IADLs (IRR 1.44, 95% CI 1.16-1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers' performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers. Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.

Trends of hospitalizations for ambulatory care-sensitive cardiovascular conditions in the municipality of Senador Canedo, Goiás, Brazil, 2001-2016.

to analyze trends of hospitalization for ambulatory care-sensitive cardiovascular conditions (ACSCC). this was an ecological study of time series of rates of hospitalization for ACSCC in the municipality of Senador Canedo, GO, Brazil, 2001-2016; we used data from the Hospital Information System and population estimates provided by the Inter-Agency Health Information Network (RIPSA) and the Brazilian Institute of Geography and Statistics (IBGE); the Prais-Winsten method was used to analyze trends. we used data on 3,244 hospitalizations for ACSCC; there was decreasing trend in the rate of hospitalizations for ACSCC (annual increase rate [AIR] = -8.14 - 95%CI -11.78;-4.35) and in the heart failure rate (AIR = -12.07 - 95%CI -14.75;-9.30); hospitalization rate time trends for hypertension, angina and cerebrovascular diseases were stationary. rates of hospitalization for ACSCC and heart failure decreased, however rates for hypertension, angina and cerebrovascular diseases remained constant.

Hospitalization for ambulatory care-sensitive conditions in the state of Rondônia, Brazil: a descriptive study of the period 2012-2016.

to describe the frequency and reasons for hospitalizations for ambulatory care-sensitive conditions (HACSC) in Rondônia, Brazil, between 2012 and 2016, and to analyze their relationship with the evolution of the coverage of the family health strategy (FHS) in the same period. this was a descriptive study of secondary data from the Brazilian National Health System's Hospital Information System. during the period of the study 133,958 HACSC were authorized, corresponding to a rate of 75 hospitalizations/1,000 inhab.; there was a parallel annual increase in FHS coverage and a slightly decreasing trend of authorized HACSC, although this was not statistically significant; in 2012, HACSC frequency was 20.7% in relation to all hospitalizations that occurred in the state, while in 2016 this indicator declined to 16.7%. HACSC frequency in Rondônia was high between 2012 and 2016; although there was an increase in FHS coverage in the same period, this increase was not accompanied by a significant change in the frequency of HACSC registered in the state.

Immigration factors and potentially avoidable hospitalizations in Canada

ObjectiveEstimate the effect of immigration characteristics on the risk of a hospitalization for an ambulatory care sensitive condition (ACSC). Research designWe analyzed data on the Canadian resident adult population aged 18 to 74 years who responded to the 2006 long form Census. The Census data were linked to the Canadian Institute for Health Information (CIHI)’s Discharge Abstract Database (DAD) for fiscal years 2006–2007, 2007–2008, and 2008–2009. We conducted a logistic regression on the binary variable we created for an ACSC admission. MeasuresThe CIHI definition of ACSC hospitalizations was used to identify potentially avoidable hospitalizations in the DAD. Immigration factors analyzed included years in Canada, ethnic origin, and ability to speak one of the official languages. ResultsThere were 3,342,450 respondents aged between 18 and 74. Using the Canadian at birth as our reference population, recent immigrants (up to five years in Canada) had lower odds of an ACSC hospitalization, regardless of their ethnic origins, with the exception of immigrants from Oceania and from other North American countries for whom the effect was not significant. The protective effect was still present in children of immigrants (AOR=0.89). Immigrants from the Caribbean, from Southern, Eastern, and Western Europe, as well as those from East Asia had lower odds across categories of time spent in Canada. The protective effect was stronger in immigrants from East Asia and lower in those of Oceanic and other North American countries. ConclusionsOur results suggest that the healthy immigrant effect dissipates with time in Canada but remains even in children of immigrants. The protective effect differs depending on the ethnic origin of the immigrant.

Tendência dos gastos e das internações por condições sensíveis à Atenção Primária em menores de cinco anos na Bahia, Brasil

This study analyses expenditure trends in Hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs) in children. It is an ecological time-series study, including hospitalizations of children under five in Bahia, between 2000 and 2012. We calculate the annual ACSC rates, as well as the total and average expenditure on these hospitalizations. We construct linear regression analysis models for the temporal trends. Between 2000 and 2012, 810,831 ACSC hospitalizations for the under-fives were recorded in Bahia. Hospitalization rates dropped 24.7% over this period, falling from 44.6 to 33.6 per 1,000 children. The total expenditure on such admissions is estimated to be 155.8 million Brazilian Reals. When we compare the first with the last year of the series, we note a reduction of 50.4% in total expenditure. The linear regression analysis demonstrates a reduction trend in average ACSC expenditure (β = -1.20, p = 0.014), (β = -3.45, p <0.01) and total expenditure (β = -0,46, p <0.01). Despite the reductions in these indicators, ACSC rates remain high, which has a significant impact on the volume of resources spent on avoidable hospitalizations. To this end, it is important to reduce ACSC expenditure, to both improve population health and reduce hospital costs.

Determinants of ambulatory care sensitive conditions hospitalizations – the patients’ perspective

Introduction: Ambulatory care sensitive conditions ACSC are health conditions for which hospitalization or emergency care can potentially be avoided through effective prevention, diagnosis and treatment in the ambulatory care setting. In Portugal, ACSC represent 12% of hospitalizations and an estimated financial impact of up to 450 million€. ACSC hospitalizations ACSH have been used as an indirect indicator of access and quality of ambulatory care and have also been suggested to measure integrated health services delivery. Despite previous research on ACSH determinants few studies investigate the patients’ perspective. The aim of this study is to compare the perspectives of patients', healthcare professionals' and evidence on determinants for ACSH. Methods: Firstly a literature review was conducted to map the domains of ACSH determinants, from multiple perspectives patients, caregivers, and health professionals. Then thirteen semi-structured interviews were conducted to include information on the patients’ perspective. Six representatives of patients associations and seven experts on primary health care and internal medicine were interviewed and asked what patients identify as determinants for ACSH. Results: The literature review identified 8 domains of ACSH determinants. The most frequent domains were “Healthcare access”, “Disease self-management” and “Individual characteristics”. While in “Healthcare access” and “Disease self-management” domains the most frequent determinants highlighted “Poor coordination across levels of care” and “Therapeutic adherence” in the “Individual characteristics” domain no determinant predominated. The interviewed representatives of patients associations identified more frequently “Inadequacy of available healthcare services” for the “Healthcare access” domain, “Non-stablished therapeutic plan” for “Disease self-management” domain, and “Dietary habits” for “Lifestyle” domain. Still, professionals interviewed stated equally “Poor coordination across levels of care” and “Difficulty to consult a practitioner” for “Healthcare access”, “Incapability to self-manage disease” for “Disease self-management” domain, as well as problems with “Formal care” for “Social support” domain. Discussion: The patients’ perspective about ACSH determinants is important to understand elements that quantitative methods and healthcare professionals’ perspective cannot explain. “Healthcare access” was the most referred domain on all perspectives being “Poor coordination across levels of care” the most referred determinant, eliciting the needs for integrated healthcare delivery. Other determinants were valued differently. Patients’ representatives elicited determinants related to patients’ daily behavior influencing status of disease. As stated by other studies, healthcare professionals highlighted specific needs of complementary care that are necessary for some patients groups. The limited number of interviews is a recognized limitation. Conclusion: The determinants for ACSH identified in the literature review and interviews differed, despite “Healthcare access” items predominating among these two methods. Based on a literature review and interviews, it appears that listening to the patients’ perspective about determinants for ACSH might allow to prioritize intervention with the focus on minimizing ACSH. Future research: In the future, the most important domains of determinants of ACSH will be assessed through a patient survey to be developed. Specific sets of questions for some ACSC may be justified. Funding acknowledgment WHO European Center for Primary Health Care

Hospitalization for mental health related ambulatory care sensitive conditions: what are the trends for First Nations in British Columbia?

BackgroundIndigenous peoples globally experience a disproportionate burden of mental illness due to forced policies and practices of colonization and cultural disruption. The objective of this study was to provide a baseline profile of hospitalization rates for mental health-related Ambulatory Care Sensitive Conditions among First-Nations living both on and off reserve in British Columbia, Canada, and explore the relationship between local access to health services and mental health-related hospitalization rates.MethodsA population-based time trend analysis of mental health-related Ambulatory Care Sensitive Conditions hospitalizations was conducted using de-identified administrative health data. The study population included all residents eligible under the universal British Columbia Medical Services Plan and living on and off First Nations reserves between 1994/95 and 2009/10. The definition of mental health-related Ambulatory Care Sensitive Conditions included mood disorders and schizophrenia, and three different change measures were used to operationalize avoidable hospitalizations: 1) rates of episodes of hospital care, 2) rates of length of stay, and 3) readmission rates. Data were analyzed using generalized estimating equations approach, controlling for age, sex, and socio-economic status, to account for change over time.ResultsOur findings show that First Nations living on reserve have higher hospitalization rates for mental disorders compared to other British Columbia residents up until 2008. Those living off reserve had significantly higher hospitalization rates throughout the study period. On-reserve communities served by nursing stations had the lowest rates of hospitalization whereas communities with limited local services had the highest rates. Compared to other British Columbia residents, all First Nations have a shorter length of stay and lower readmission rates.ConclusionsThis study suggests that despite reduced rates of hospitalization for mental-health related Ambulatory Care Sensitive Conditions over time for First Nations, gaps in mental health care still exist. We argue greater investments in primary mental health care are needed to support First Nations health. However, these efforts should place equal importance on prevention and the social determinants of health.

Associations between structures and resources of primary care at the district level and health outcomes: a case study of diabetes mellitus care in Thailand

BackgroundThe structural factors of primary care potentially influence its performance and quality. This study investigated the association between structural factors, including available primary care resources and health outcomes, by using diabetes-related ambulatory care sensitive conditions hospitalizations under the Universal Coverage Scheme in Thailand.MethodsA 2-year panel study used secondary data compiled at the district level. Administrative claim data from 838 districts during the 2014–2015 fiscal years from the National Health Security Office were used to analyze overall diabetes mellitus (DM) hospitalizations and its three subgroups: hospitalizations for uncontrolled diabetes, short-term complications, and long-term complications. Primary care structural data were obtained from the Ministry of Public Health. Generalized estimating equations were used to estimate the influence of structural factors on the age-standardized DM hospitalization ratio.ResultsA higher overall DM and uncontrolled diabetes hospitalization ratio was related to an increasing concentration of outpatient utilization (using the Herfindahl–Hirschman Index) (overall DM; beta [standard error, SE]=0.003 [0.001], 95% CI 0.000, 0.006) and decreasing physician density and bed supply (overall DM; beta [SE]=−1.350 [0.674], 95% CI −2.671, −0.028), beta [SE]=−0.023 [0.011], 95% CI −0.045, −0.001, respectively). Hospitalizations for short-term complications increased with a decrease in health care facility density, whereas hospitalizations for long-term complications increased as that density increased. Rurality was strongly associated with higher hospitalization ratios for all DM hospitalizations except short-term complications.ConclusionsThis study identified structural factors associated with health outcomes, many of which can be changed through reorganization at the district level.