Hospitalizations For Ambulatory Care Sensitive Conditions Research Articles

National Norms for Hospitalizations Due to Ambulatory Care Sensitive Conditions among Adults in the US.

Ambulatory care sensitive conditions (ACSCs) are acute or chronic health issues that lead to potentially preventable hospitalizations when not treated in the outpatient primary care setting. To describe national hospitalization rates due to ACSCs among adult inpatients in the US. A retrospective cross-sectional analysis of the 2018 US National Inpatient Sample (NIS) dataset from the Healthcare Cost and Utilization Project at the Agency of Healthcare Research and Quality was completed in the year 2022. Participants were adult inpatients from community hospitals in 48 states of the US and District of Columbia. ACSC admission rates were calculated using ICD-10 codes and the Purdy ACSC definition. The admission rates were weighted to the US inpatient population and stratified by age, sex, and race. ACSC hospitalization rates varied considerably across age and average number of hospitalizations varied across sex and race. ACSC hospitalization rates increased with age, male sex, and Native American and Black race. The most common ACSCs were pneumonia, diabetes, and congestive heart failure. Previous studies have emphasized the importance of preventable hospitalizations, however, the national rates for ACSC hospitalizations across all ages in the US have not been reported. The national rates presented will facilitate comparisons to identify hospitals and health care systems with higher-than-expected rates of ACSC admissions that may suggest a need for improved primary care services.

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare

Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges. To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare. Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022. Hospitalizations, observation stays, and ED direct discharges for ACSCs. The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12). The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.

Incipient dementia and avoidable hospital admission in persons with osteoarthritis

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

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

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

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

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

Sickle Cell Disease May Qualify As an Ambulatory Care Sensitive Condition

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

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

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

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

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

Income, education, and hospitalization in Canada: results from linked census and administrative data

BackgroundAddressing population health inequities begins with quantifying how social factors affect the health and health care utilization of individuals. Such quantification relies on the availability of detailed health and demographic data. Unfortunately, administrative health care data rarely includes detailed demographic information. Data linkage, which combines administrative health data with national-level census or survey data, enables researchers to examine socio-economic inequalities in health care utilization in greater detail.Data and methodsWith access to a unique Canadian dataset linking data from the Hospital Discharge Database (DAD) from 2006 to 2007 with detailed individual-level socio-demographic data from the 2006 Canadian Census, we are able to examine the patterning of hospitalization in Canada in the early 2000s across a variety of socio-demographic variables. We examine the association of education and income, controlling for immigration status, rural residence, marital status and ethnicity, with hospitalization rates for both ambulatory care sensitive conditions (ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) for children and youth, working-age adults, and older adults, in models stratified by sex.ResultsAge standardized hospitalization rates show that there is a clear socio-economic gradient in hospitalization in Canada in the 2000s. Education and income are independently, inversely associated with hospitalization for males and females across three broad age groups. These associations are stronger for ACSCs than non-ACSCs. The association of other socio-demographic variables, such as immigrant status, and rural residence is also stronger for hospitalization for ACSCs. The association of socio-economic status with hospitalization for ACSCs is strongest for working age women and men, and is somewhat attenuated for older adults.ConclusionsLower socio-economic status is associated with a higher likelihood of hospitalization for men and women in Canada across three broad age groups in the 2000s. These associations are stronger for ACSCs, suggesting that in addition to increased likelihood of disease, decreased access to preventative care may be driving up hospitalization rates for marginalized groups. We conclude with the recommendation that in order to track progress in reducing health inequities, health systems should either collect detailed individual-level socio-demographic data or link their administrative health data to existing demographic data sets.

The COVID – 19 pandemic influence on hospitalizations for ambulatory care-sensitive condition

Abstract Aim To explore whether the COVID-19 pandemic influenced hospitalizations for ambulatory care-sensitive conditions (ACSCs) during the COVID-19 pandemic in Split-Dalmatia County, Croatia. Methods We employed a cross-sectional comparative study using two different time periods, the prepandemic (March 2019 to February 2020) and the pandemic (March 2020 to February 2021) to explore possibilities of COVID-19 pandemic influence on hospitalizations for ambulatory care-sensitive conditions (ACSCs) during the COVID-19 pandemic in Split-Dalmatia County. The research used data from the national information system on hospitalizations from the Clinical Hospital Center Split, University Hospital Split. The ACSCs was classified in the categories of vaccine preventable, chronic and acute disease. The indicators were statistically analysed. The z-score test for two population proportions is used. Results During prepandemic (March 2019 to February 2020) there were 48,289 hospitalizations, in the pandemic period (March 2020 to February 2021) there were 37,999 hospitalizations. The ACSCs hospitalizations made 6.4% in the prepandemic and 7.1% in the pandemic period. In the pandemic there was a significantly higher ACSCs hospitalizations compared to the prepandemic (z =-3.9348; p = 0.00008; p &amp;lt; 0), which was supported by a significant increase regarding ACSCs hospitalizations in the category of acute diseases, among women (z=-3.6614; p = 0.00026; p &amp;lt; 0 .05), in age groups 0-19 years (z=-4.0492; p &amp;lt; 0.00001; p &amp;lt; 0.05) and 20-64 years (z= -3.8818; p = 0 .0001; p &amp;lt; 0.05). Conclusions The results of the study show that the COVID-19 pandemic contributed to the total number of hospitalizations as well as the hospitalization of the ACSC. One of the reasons for these changes was certainly the changed organization of the work of the entire health system due to the COVID-19 pandemic. Key messages • The results of the study show that the COVID-19 pandemic contributed to the total number of hospitalizations as well as the hospitalization of the ACSC. • One of the reasons for these changes was certainly the changed organization of the work of the entire health system due to the COVID-19 pandemic.

Inequalities in hospitalizations for ambulatory care sensitive conditions in New York City before and after the affordable care act

AbstractThe Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid program, creating health insurance exchanges (now called “marketplaces”) in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre‐existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care‐sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.

Outpatient Care Fragmentation and Acute Care Utilization in Veterans Affairs Home-Based Primary Care

Veterans Affairs (VA) Home-Based Primary Care (HBPC) provides comprehensive, interdisciplinary primary care at home to patients with complex, chronic, disabling disease, but little is known about care fragmentation patterns and consequences among these patients. To examine outpatient care fragmentation patterns and subsequent acute care among HBPC-engaged patients at high risk of hospitalization or death. This retrospective cohort study included VA patients aged at least 65 years who were enrolled in the VA and Medicare, whose risk of hospitalization or death was in the top 10%, and who had at least 4 outpatient visits between October 1, 2013, and September 30, 2014. HBPC engagement was defined as having at least 2 HBPC encounters between July 1, 2014, and September 30, 2014. Data were analyzed from March 2020 to March 2022. Two indices of outpatient care fragmentation: practitioner count and the Usual Provider Continuity Index (UPC), based on VA and non-VA health care use from October 1, 2013, to September 30, 2014. All care delivered by HBPC clinicians was analyzed as coming from a single practitioner. Emergency department (ED) visits and hospitalizations for ambulatory care sensitive conditions (ACSC) from VA records and Medicare claims from October 1, 2014, to September 30, 2015. Among 8908 identified HBPC patients, 8606 (96.6%) were male, 1562 (17.5%) were Black, 249 (2.8%) were Hispanic, 6499 (73.0%) were White, 157 (1.8%) were other race or ethnicity, and 441 (5.0%) had unknown race or ethnicity; the mean (SD) age was 80.0 (9.02) years; patients had a mean (SD) of 11.25 (3.87) chronic conditions, and commonly had disabling conditions such as dementia (38.8% [n = 3457]). In adjusted models, a greater number of practitioners was associated with increased odds of an ED visit (adjusted odds ratio [aOR], 1.05 [95% CI, 1.03-1.07]) and hospitalization for an ACSC (aOR, 1.04 [95% CI, 1.02-1.06]), whereas more concentrated care with a higher UPC was associated with reduced odds of these outcomes (highest vs lowest tertile of UPC: aOR for ED visit, 0.77 [95% CI, 0.67-0.88], aOR for ACSC hospitalization, 0.78 [95% CI, 0.68-0.88]). Among patients in HBPC, fragmented care was associated with more ED visits and ACSC hospitalizations. These findings suggest that consolidating or coordinating fragmented care may be a target for reducing preventable acute care.

The impact of not having a primary care provider on emergency department utilization and hospitalizations before and during COVID-19: A novel retrospective cohort study linking primary care waitlists with administrative billing data.

ObjectivesPrimary care attachment improves access, chronic disease prevention and management. Growing proportions of Canadians are unattached and registering with provincial primary care waitlists for family doctors or nurse practitioners. We compare emergency department utilization and hospitalization by waitlist registration status both before and during the first two waves of COVID-19. ApproachThis study is the first to link a provincial primary care waitlist with routinely collected administrative billing data. Access and linking required collaboration and processes to establish permissions and rigour. A descriptive cohort design estimates quarterly population-based rates of emergency department utilization and ambulatory care sensitive condition (ACSC) hospitalizations among persons on and off the waitlist between Jan/01/2017-Dec/24/2020. Emergency department utilization and ACSC hospitalization rates by current waitlist status were quantified from physician claims and hospitalization data. Relative differences during COVID-19 first (Q2 2020; April-June 2020) and second waves (Q4 2020; October-December 2020) were compared with the previous year. ResultsCentralized waitlist and administrative billing data were successfully linked. During the study period, 100,867 primary care-eligible Nova Scotians (10.1% of the population) were on the waitlist. Those on the waitlist had higher emergency department utilization each quarter, and more ACSC hospitalizations for most quarters, than those not on the waitlist. Emergency department utilization was higher for individuals ≥65 years and females; lowest during the first two COVID-19 waves; and differed more by waitlist status for those &lt;65 years. Emergency department contacts and ACSC hospitalizations decreased during COVID-19 relative to the previous year. Emergency department utilization during COVID-19 was lower compared to analogous previous year quarters and this relative difference was more pronounced for those on the waitlist during the second wave of COVID-19. ConclusionLinking novel data sources identified that Nova Scotians seeking primary care attachment utilize hospital-based services more frequently than those not on the waitlist. Both groups had lower utilization during the COVID-19 pandemic than the year before. The degree to which forgone services produces downstream health burden remains to be seen.

Trends in all-cause mortality and inpatient and outpatient visits for ambulatory care sensitive conditions during the first year of the COVID-19 pandemic: A population-based study.

BackgroundThe impact of the COVID‐19 pandemic on the management of ambulatory care sensitive conditions (ACSCs) remains unknown.ObjectivesTo compare observed and expected (projected based on previous years) trends in all‐cause mortality and healthcare use for ACSCs in the first year of the pandemic (March 2020 to March 2021).Design, Setting and ParticipantsWe conducted a population‐based study using provincial health administrative data on general adul population (Ontario, Canada).Outcomes and MeasuresMonthly all‐cause mortality, and hospitalizations, emergency department (ED) and outpatient visit rates (per 100,000 people at‐risk) for seven combined ACSCs (asthma, chronic obstructive pulmonary disease, angina, congestive heart failure, hypertension, diabetes, and epilepsy) during the first year were compared with similar periods in previous years (2016–2019) by fitting monthly time series autoregressive integrated moving‐average models.ResultsCompared to previous years, all‐cause mortality rates increased at the beginning of the pandemic (observed rate in March to May 2020 of 79.98 vs. projected of 71.24 [66.35–76.50]) and then returned to expected in June 2020—except among immigrants and people with mental health conditions where they remained elevated. Hospitalization and ED visit rates for ACSCs remained lower than projected throughout the first year: observed hospitalization rate of 37.29 versus projected of 52.07 (47.84–56.68); observed ED visit rate of 92.55 versus projected of 134.72 (124.89–145.33). ACSC outpatient visit rates decreased initially (observed rate of 4299.57 vs. projected of 5060.23 [4712.64–5433.46]) and then returned to expected in June 2020.

Using Ambulatory Care Sensitive Conditions to Assess Primary Health Care Performance during Disasters: A Systematic Review.

Ambulatory care sensitive conditions (ACSCs) are health conditions for which appropriate primary care intervention could prevent hospital admission. ACSC hospitalization rates are a well-established parameter for assessing the performance of primary health care (PHC). Although this indicator has been extensively used to monitor the performance of PHC systems in peacetime, its consideration during disasters has been neglected. The World Health Organization (WHO) has acknowledged the importance of PHC in guaranteeing continuity of care during and after a disaster for avoiding negative health outcomes. We conducted a systematic review to evaluate the extent and nature of research activity on the use of ACSCs during disasters, with an eye toward finding innovative ways to assess the level of PHC function at times of crisis. Online databases were searched to identify papers. A final list of nine publications was retrieved. The analysis of the reviewed articles confirmed that ACSCs can serve as a useful indicator of PHC performance during disasters, with several caveats that must be considered. The reviewed articles cover several disaster scenarios and a wide variety of methodologies showing the connection between ACSCs and health system performance. The strengths and weaknesses of using different methodologies are explored and recommendations are given for using ACSCs to assess PHC performance during disasters.

The association between primary care use and potentially-preventable hospitalization among dual eligibles age 65 and over

BackgroundIndividuals dually-enrolled in Medicare and Medicaid (dual eligibles) are disproportionately sicker, have higher health care costs, and are hospitalized more often for ambulatory care sensitive conditions (ACSCs) than other Medicare beneficiaries. Primary care may reduce ACSC hospitalizations, but this has not been well studied among dual eligibles. We examined the relationship between primary care and ACSC hospitalization among dual eligibles age 65 and older.MethodsIn this observational study, we used 100% Medicare claims data for dual eligibles ages 65 and over from 2012 to 2018 to estimate the likelihood of ACSC hospitalization as a function of primary care visits and other factors. We used linear probability models stratified by rurality, with subgroup analyses for dual eligibles with diabetes or congestive heart failure.ResultsEach additional primary care visit was associated with an 0.05 and 0.09 percentage point decrease in the probability of ACSC hospitalization among urban (95% CI: − 0.059, − 0.044) and rural (95% CI: − 0.10, − 0.08) dual eligibles, respectively. Among dual eligibles with CHF, the relationship was even stronger with decreases of 0.09 percentage points (95% CI: − 0.10, − 0.08) and 0.15 percentage points (95% CI: − 0.17, − 0.13) among urban and rural residents, respectively.ConclusionsIncreased primary care use is associated with lower rates of preventable hospitalizations for dual eligibles age 65 and older, especially for dual eligibles with diabetes and congestive heart failure. In turn, efforts to reduce preventable hospitalizations for this dual-eligible population should consider how to increase access to and use of primary care.

The Impact of Rural Hospital Closures and Health Service Restructuring on Provincial- and Community-Level Patterns of Hospital Admissions in New Brunswick.

In the early 2000s, the Province of New Brunswick, Canada, undertook health system restructuring, including closing some rural hospitals. We examined whether changes in geographic access to hospitals and primary care were associated with changes in patterns of hospital use. We described three measures of hospital use for ambulatory care sensitive conditions (ACSCs) among adults 75 years and younger annually during the period 2004–2013 overall, and at the community scale. We described spatial and temporal patterns in: age-standardized hospitalization rates, age-standardized incidence of hospital admissions, and rates of admissions via ambulance. Overall, rates and incidence of hospitalizations for ACSCs declined while admissions via ambulance remained largely unchanged. We observed considerable regional variation in rates between communities in 2004. This regional variation decreased over time, with rural areas demonstrating the sharpest declines. Changes in hospital service provision within individual communities had little impact on rates of ACSC admissions. Results were consistent across urban and rural communities and were robust to analyses that included older patients and those admitted for reasons other than ACSCs. Our results suggest that the restructuring and hospital closures did not result in substantial changes to regional patterns or rates of service use.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study.

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs. We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression. Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin. Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Trends in Hospitalizations for Ambulatory Care–Sensitive Conditions During the COVID-19 Pandemic

The association of the COVID-19 pandemic with the quality of ambulatory care is unknown. Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are a well-studied measure of the quality of ambulatory care; however, they may also be associated with other patient-level and system-level factors. To describe trends in hospital admissions for ACSCs in the prepandemic period (March 2019 to February 2020) compared with the pandemic period (March 2020 to February 2021). This cross-sectional study of adults enrolled in a commercial health maintenance organization in Michigan included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period. COVID-19 pandemic (March 2020 to February 2021). Adjusted relative risk (aRR) of ACSC hospitalizations and intensive care unit stays for ACSC hospitalizations and adjusted incidence rate ratio of the length of stay of ACSC hospitalizations in the prepandemic (March 2019 to February 2020) vs pandemic (March 2020 to February 2021) periods, adjusted for patient age, sex, calendar month of admission, and county of residence. The study population included 1 240 409 unique adults (13 011 176 person-months) in the prepandemic period and 1 206 361 unique adults (12 759 675 person-months) in the pandemic period, in which 51.3% of person-months (n = 6 547 231) were for female patients, with a relatively even age distribution between the ages of 24 and 64 years. The relative risk of having any ACSC hospitalization in the pandemic period compared with the prepandemic period was 0.72 (95% CI, 0.69-0.76; P < .001). This decrease in risk was slightly larger in magnitude than the overall reduction in non-ACSC, non-COVID-19 hospitalization rates (aRR, 0.82; 95% CI, 0.81-0.83; P < .001). Large reductions were found in the relative risk of respiratory-related ACSC hospitalizations (aRR, 0.54; 95% CI, 0.50-0.58; P < .001), with non-statistically significant reductions in diabetes-related ACSCs (aRR, 0.91; 95% CI, 0.83-1.00; P = .05) and a statistically significant reduction in all other ACSC hospitalizations (aRR, 0.79; 95% CI, 0.74-0.85; P < .001). Among ACSC hospitalizations, no change was found in the percentage that included an intensive care unit stay (aRR, 0.99; 95% CI, 0.94-1.04; P = .64), and no change was found in the length of stay (adjusted incidence rate ratio, 1.02; 95% CI, 0.98-1.06; P = .33). In this cross-sectional study of adults enrolled in a large commercial health maintenance organization plan, the COVID-19 pandemic was associated with reductions in both non-ACSC and ACSC hospitalizations, with particularly large reductions seen in respiratory-related ACSCs. These reductions were likely due to many patient-level and health system-level factors associated with hospitalization rates. Further research into the causes and long-term outcomes associated with these reductions in ACSC admissions is needed to understand how the pandemic has affected the delivery of ambulatory and hospital care in the US.

A cross-sectional study of community-level physician retention and hospitalization in rural Ontario, Canada.

Many rural communities experience poor family physician retention. We examined the association between community-level physician retention and hospitalization for all causes and ambulatory care-sensitive conditions (ACSCs) in 2017 among residents of rural communities in Ontario, Canada. We conducted a population-based cross-sectional study by linking administrative data from the public health insurance program in Ontario. To create the physician retention measure for each rural community, we divided the number of family physicians who worked in the community in both 2016 and 2017 by the total number of unique family physicians in the community in either year. We grouped retention level by tertile and added a fourth category, "no physician" to include communities that did not have any residing physicians in either 2016 or 2017. Outcomes were all-cause hospitalization and ACSC hospitalization between April 1, 2017 and March 31, 2018. Among 1,436,794 rural residents, there were 93,752 all-cause hospitalizations and 8,691 ACSC hospitalizations in 2017. After controlling for other predictors, compared to residents in low-retention communities, residents of medium- and high-retention communities were 0.888 (95% CI: 0.868-0.909) and 0.937 (95% CI: 0.915-0.960) times as likely to have all-cause hospitalization, and residents of high-retention communities were 0.918 (95% CI: 0.858-0.981) times as likely to have ACSC hospitalization in 2017. Community-level physician retention is significantly associated with all cause and ACSC hospitalization in rural communities in Ontario, and may serve as an alternate measure to assess the impact of disrupted continuity of care.