Hospitalizations For Ambulatory Care Sensitive Conditions Research Articles

Colocated General Medical Care and Preventable Hospital Admissions for Veterans With Serious Mental Illness

This study examined whether veterans with serious mental illness in mental health settings with colocated general medical care had fewer hospitalizations for ambulatory care-sensitive conditions than veterans in other settings. Using 2007 data, the study examined hospitalizations for ambulatory care-sensitive conditions with zero-inflated negative binomial regression controlling for demographic, clinical, and facility characteristics. Of 92,268 veterans with serious mental illness, 9,662 (10.5%) received care at ten sites with colocated care and 82,604 (89.5%) at 98 sites without it. At sites without colocation, 5.1% had a hospitalization for an ambulatory care-sensitive condition, compared with 4.3% at sites with colocation. Attendance at sites with colocated care was associated with an adjusted count of hospitalizations of .76 compared with attendance at sites with no colocation (β=-.28, 95% confidence interval=.47 to -.09, p=.004). Colocation of general medical services in the mental health setting was associated with significantly fewer preventable hospitalizations.

Predictors of Avoidable Hospitalizations Among Assisted Living Residents

Hospitalizations for long term care residents, including those from assisted living facilities (ALFs), are very costly, often traumatic, and increase risk for iatrogenic disorders for those involved. Currently, hospital expenditures account for approximately one-third of total national health care spending. Hospitalizations for ambulatory care-sensitive (ACS) conditions are considered potentially avoidable, as these are physical health conditions that can often be treated safely at a lower level of care or occur as a result of lack of timely, adequate treatment at a lower level of care. The goal was to examine risk factors for hospitalization for an ACS condition of Medicaid-enrolled younger and older ALF residents during 2003-2008. This is a retrospective cohort study that used 5 years of Medicaid enrollment and fee-for-service claims data. The study sample included 16,208 Medicaid-enrolled ALF residents in Florida, 7991 (49%) of whom were 65 years of age or older. In total, study participants had 22,114 hospitalizations, 3759 (17%) of which were for an ACS condition. Sixteen percent of all ALF residents (n = 2587), about 12% of the younger residents and 20% of the older residents, had at least one ACS hospitalization. ACS hospitalizations constitute 13% of all hospitalizations for the younger residents and 22% of all hospitalizations for the older residents. Using Cox proportional hazard regression, we found that for both age groups, increased age, being Hispanic or of other race/ethnicity, and having comorbid physical health conditions were associated with a higher risk of ACS hospitalization. For older residents, having a dementia diagnosis and being African American reduced the risk of ACS hospitalization, whereas for younger residents having a major psychotic disorder reduced the risk of ACS hospitalization. The results highlight the need for increased education, communication, and future research on these predictive factors. The increased frequency of hospitalization for ACS conditions among ALF residents with minority status and older age may well indicate that their more complex health care needs are not being adequately addressed. The role of serious mental illness and dementia in risk for ACS hospitalization also deserves further attention.

Increased Risk of Avoidable Hospitalization among Patients with Schizophrenia

Some studies suggest that hospitalizations for certain conditions, called ambulatory care sensitive conditions (ACSCs), are potentially avoidable. However, almost no study has addressed the risk of ACSC hospitalizations specifically for patients with severe mental illness. Our study examines the risk of ACSC hospitalizations among patients with schizophrenia in Taiwan, using a 5-year, nationwide, population-based database. Our study included 2503 patients with schizophrenia and 20 024 matched patients without schizophrenia. Poisson regression analysis was then performed in which the number of ACSC hospitalizations from 2002 to 2006 (including ruptured appendix, asthma, cellulitis, congestive heart failure, diabetes, gangrene, hypokalemia, immunizable conditions, malignant hypertension, pneumonia, pyelonephritis, and perforated or bleeding ulcer) was regressed against the independent variable of whether or not a patient had a schizophrenia diagnosis in 2001. Results show that 9.83% of patients with schizophrenia and 4.71% of patients in the comparison group experienced ACSC hospitalizations from 2002 to 2006. After adjusting for each patient's sex, age, level of urbanization, geographic location of residence within a community, and monthly income, patients with schizophrenia had a 3.26-fold higher (95% CI 3.00 to 3.54, P < 0.001) risk of experiencing ACSC hospitalizations than the comparison participants. After excluding the conditions of diabetes, hypertension, and asthma, patients with schizophrenia independently had a 2.46-fold higher risk of ACSC hospitalizations (95% CI 2.12 to 2.86, P < 0.001), compared with participants in the comparison group. We conclude that schizophrenia patients are at a higher risk for hospitalizations owing to ACSCs, despite a national health insurance system providing universal coverage to citizens.

Older Adults’ Inpatient and Emergency Department Utilization for Ambulatory-Care-Sensitive Conditions: Relationship With Alcohol Consumption

This study examined the relationship between drinking that exceeds guideline-recommended limits and acute-care utilization for ambulatory-care-sensitive conditions (ACSCs) by older Medicare beneficiaries. This secondary data analysis used the 2001-2006 Medicare Current Beneficiary Survey (unweighted n = 5,570 community dwelling, past-year drinkers, 65 years and older). Self-reported alcohol consumption (categorized as within guidelines, exceeding monthly but not daily limits, or heavy episodic) and covariates were used to predict ACSC hospitalization, emergency department visit not resulting in admission, and emergency department visit that did result in admission. Heavy episodic drinking was significantly associated with higher likelihood of an ACSC emergency department visit not resulting in admission (adjusted odds ratio = 1.91, 95% CI: 1.11-3.30; p < .05). Drinking pattern was not significant for other ACSC measures. Results partially support the hypothesis that excessive drinking may be related to ACSC acute-care utilization among older adults, suggesting increased risk of lower quality outpatient care.

Unhealthy competition: consequences of health plan choice in California Medicaid.

We compared the quality of care received by managed care Medicaid beneficiaries in counties with a choice of health plans and counties with no choice. This cross-sectional study among California Medicaid beneficiaries was conducted during 2002. We used a multivariate Poisson model to calculate adjusted rates of hospital admissions for ambulatory care-sensitive conditions by duration of plan enrollment. Among beneficiaries with continuous Medicaid coverage, the percentage with 12 months of continuous enrollment in a health plan was significantly lower in counties with a choice of plans than in counties with no choice (79.2% vs 95.2%; P < .001). Annual ambulatory care-sensitive admission rates adjusted for age, gender, and race/ethnicity were significantly higher among beneficiaries living in counties with a choice of plans (6.58 admissions per 1000 beneficiaries; 95% confidence interval [CI] = 6.57, 6.58) than among those in counties with no choice (6.27 per 1000; 95% CI = 6.27, 6.28). Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.

Have investments in on-reserve health services and initiatives promoting community control improved First Nations’ health in Manitoba?

The objective of this study was to document the relationship between First Nation's community characteristics and the rates of hospitalization for Ambulatory Care Sensitive Conditions (ACSC) in the province of Manitoba, Canada. A population-based time trend analysis of selected ACSC was conducted using the de-identified administrative data housed at the Manitoba Centre for Health Policy, including vital statistics and health information. The study population included all Manitoba residents eligible under the universal Manitoba Health Services Insurance Plan and living on First Nation reserves between 1984/85 and 2004/05. Twenty-nine ACSC defined using 3, 4 and 5 digit ICD-9-CM and ICD-10-CM codes permitted cross-sectional and longitudinal comparison of hospitalization rates. The analysis used Generalized Estimated Equation (GEE) modeling. Two variables were significant in our model: level of access to primary health care on-reserve; and level of local autonomy. Communities with local access to a broader complement of primary health care services showed a lower rate of hospitalization for ACSC. We also examined whether there was a significant trend in the rates of hospitalization for ACSC over time following the signature of an agreement increasing local autonomy over resource allocation. We found the rates of hospitalization for ACSC decreased with each year following the signature of such an agreement. This article demonstrates that communities with better local access to primary health care consistently show lower rates of ACSC. Secondly, the longer community health services have been under community control, the lower its ACSC rate.

Are Smoking and Alcohol Misuse Associated with Subsequent Hospitalizations for Ambulatory Care Sensitive Conditions?

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are used to assess quality of care, but studies rarely adjust for health behaviors. This study evaluated whether results of smoking or alcohol screening were associated with hospitalizations for ACSCs. Participants included 33,273 male Veterans Affairs general medicine outpatients who returned mailed surveys. The main outcome was hospitalization with a primary discharge diagnosis for an ACSC in the year following screening. Analyses were adjusted for demographics, comorbidity, and other health behaviors. Current and previous smoking and abstaining from alcohol were associated with significantly increased risk of hospitalization for ACSCs, but alcohol misuse was not. However, severe alcohol misuse was associated with increased risk of hospitalizations with a primary or secondary ACSC discharge diagnosis. When ACSCs are used to evaluate the quality of care, health systems caring for populations with higher rates of smoking or nondrinking could falsely appear to have poorer quality care if alcohol and tobacco use are not considered.

Trends and geographic variation of potentially avoidable hospitalizations in the veterans health-care system

The rate of hospitalizations due to ambulatory care-sensitive conditions (ACSCs) has been widely accepted as an indicator of access and quality of primary care. This study aimed to examine the trends and geographic variation of ACSC hospitalizations in US veterans health-care system, to identify factors associated with ACSC hospitalizations and to develop a quality indicator that can monitor access and effectiveness of primary care at hospital level. Using fiscal years 1997-2007 data, we found total ACSC hospitalizations per 1000 ACSC patients decreased by 58%; ACSC hospitalizations as percentage of total hospitalizations decreased 9%. However, significant geographic variations of ACSC hospitalizations remained and we found that adjustment of case-mix or confounding factors was essential in making meaningful comparisons among hospitals in a health-care system. Further, this study also reveals that low-income veterans still had higher ACSC hospitalization rates and patient travel time less than 30 minutes to the nearest VA providers was associated with fewer ACSC hospitalizations, which possess important policy implications.

Access to Care and the Incidence of Endstage Renal Disease Due to Systemic Lupus Erythematosus

Persons with low socioeconomic status have an increased risk of endstage renal disease (ESRD) due to systemic lupus erythematosus (SLE), possibly because of limited access to care. We examined if the incidence of ESRD due to SLE was higher in geographic areas with poorer access to care. In this population-based ecological study, we tested associations between the incidence of ESRD due to SLE and the proportion of hospitalizations with no insurance, Medicaid or managed care insurance, residence in a primary care-provider shortage area or rural area, and rate of hospitalizations for ambulatory care-sensitive conditions, by ZIP code in California in 1999-2004. The incidence of ESRD due to SLE was higher in ZIP codes with higher proportions of hospitalizations with no insurance (r = 0.22, p < 0.0001) or Medicaid (r = 0.21, p < 0.0001), and in ZIP codes with higher rates of hospitalizations for ambulatory care-sensitive conditions (r = 0.23, p < 0.0001). In multivariate analyses, incidences were higher in ZIP codes with higher proportions of hospitalizations with Medicaid (p < 0.0001) and higher rates of hospitalizations for ambulatory care-sensitive conditions (p = 0.06), independent of the socioeconomic status of the ZIP code residents. The incidence of ESRD due to SLE is higher in areas with higher proportions of residents who have public insurance and higher rates of avoidable hospitalizations, suggesting that limited access to care may contribute to this complication of SLE.

Racial Disparities in Hospitalizations for Ambulatory Care–Sensitive Conditions

Variation in the quality of ambulatory care may be a key factor in explaining disparities in health, and these disparities have large cost implications. This study identified differences in hospitalization rates for elderly African-American and white Marylanders for eight ambulatory care-sensitive conditions (ACSCs). It assessed the relative contribution of race to disparities in preventable hospitalizations after controlling for demographic and socioeconomic factors as well as underlying prevalence. It also estimated the excess cost associated with these disparities. Using prevention quality indicator specifications from the Agency for Healthcare and Research Quality applied to 2006 Medicare claims data, eight ACSC hospitalization measures were developed for 569,896 Maryland Medicare beneficiaries. The analysis was conducted in 2008. A Poisson regression model identified race, age, gender, and income as factors associated with differences in ACSC hospitalization rates. Excess costs were estimated from excess hospitalizations of African Americans and the median cost per admission. African Americans had significantly higher rates of ACSC hospitalizations than whites for five of eight conditions after controlling for demographic, socioeconomic, and geographic factors. Excess costs from disparities in quality ranged from $8 million (heart failure) to $38,000 (urinary tract infection). Race may be a key predictor of preventable hospitalizations for some ACSCs. Racial disparities in these hospitalizations represent excess costs to Medicare. Because ACSC admissions are potentially preventable with optimal ambulatory care, improving care for minority populations may reduce disparities and lower hospital costs.

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

BackgroundA relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.MethodsFrom the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.ResultsOverall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.ConclusionsThe socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

Health and Psychiatric Disparities in Children with Cognitive and Developmental Delays: Implications for Health Policy in Quebec

Background Previous research on psychiatric and health disparities according to level of cognitive functioning has focused on adults within an American healthcare context. The current study compares children with and without cognitive and developmental delays in Quebec, Canada, using physician billing data from a longitudinal study of low‐income, francophone families. Canada is an ideal context for studying medical billing data as its equal access healthcare system removes many socioeconomic biases.Methods A large sample (n = 1050) of children is used to describe psychiatric and health disparities, as well as differences in Ambulatory Care Sensitive (ACS) conditions and primary healthcare, between children with (n = 107) and without (n = 943) diagnoses in their billing history indicative of delays.Results The findings demonstrated a relatively high level of psychiatric diagnoses for children with delays. However, no difference was found between children with and without delays in regard to emergency room visits and hospitalizations for ACS conditions and primary healthcare.Conclusions The findings suggest that, within a universal healthcare system, disparities in primary healthcare may not emerge until adulthood in individuals with delay status.

Health care access in rural areas: Evidence that hospitalization for ambulatory care-sensitive conditions in the United States may increase with the level of rurality

We examined whether levels of rurality are associated with hospitalization for ambulatory care-sensitive conditions (ACSH) in eight states of the United States. ACSH is an indicator of access to reasonably effective primary health care. ACSH for children did not vary systematically with rurality. Compared to the most urban counties, the adjusted rate in the most rural was 90% greater for ages 18–64 and 45% greater for ages 65+ (both p<.001). Adjusted adult rates generally increased with the level of rurality. ConclusionsIncreasing levels of rurality may be positively associated with ACSH, suggesting rural disparities in access to primary health care.

Funding of Tribal Health Programs Linked to Lower Rates of Hospitalization for Conditions Sensitive to Ambulatory Care

To determine first whether higher funding of Tribally Operated Health Programs (TOHP) is associated with reduced hospitalizations for ambulatory care sensitive conditions (HASC) of the American Indian/Alaska Natives (AIAN) who use them after adjusting for characteristics of TOHP service areas; and then whether improved ambulatory care with higher levels of funding mediates the association. Records in the Indian Health Service (IHS) for California of an annual average 42,153 AIAN users of TOHP from 1998 to 2002 were linked with state hospital discharge records. We analyzed 3181 HASC for AIAN users of 20 TOHP in multilevel Poisson regression models to determine the association of HASC rates adjusted for individual age and gender with the Federal Disparity Index for IHS funding of TOHP. Higher IHS funding of TOHP was associated with lower HASC rates for the AIAN who use them. For TOHP with less than 60% of health care costs funded, the HASC rate dropped 12% for every increase of 10% in funding. Even adjusting for characteristics of the service areas, the effect was only slightly reduced to a value of 9% to 11%. None of the available indicators of ambulatory care tested were found to mediate the effects. Our findings are consistent with a policy of IHS funding of all TOHP at a level of at least 60% of the health care costs of the AIAN who use the programs, instead of the current policy of 40%. Additional research is needed to understand what ambulatory care characteristics are improved by the funding.

Hospitalizações entre crianças e adolescentes no território de abrangência de um serviço de Atenção Primária à saúde

A hospitalização, além de sofrimento familiar importante, é um evento de custo elevado para o sistema de saúde; além disso, ela pode ser, muitas vezes, prevenida no nível ambulatorial. Oobjetivo deste estudo foi identificar o percentual de hospitalizações por condições sensíveis à atenção ambulatorial (CSAA) que se referem àquelas em que a atenção efetiva e a tempo podem evitar internação. Foram estudadas 3.329 hospitalizações em menores de 19 anos, ocorridas nos anos de 2001 a 2004, em quatro hospitais do SUS, principais referências para uma população de áreas adscritas de um serviço de Atenção Primária em Saúde (APS). Análises univariadas e multivariadas foram empregadas para verificar associação entre variáveis independentes e a ocorrência de hospitalizações por CSAA. Identificou-se uma taxa anual de hospitalização de 2,9%. As doenças do aparelho respiratório são o grupo de causa mais freqüente (36%), seguido do grupo das perinatais (14%), infecciosas e parasitárias (10%), do aparelho digestivo (9%) e das causas externas (6%). As reinternações corresponderam a 16% do total de internações. A taxa de hospitalização por CSAA foi de 35,6%, variando de 25% a 43% entre as Unidades de APS. As variáveis relacionadas à maior ocorrência de hospitalizações por este motivo foram: idade de um a quatro anos (p&lt;0,01), ter ido direto para o hospital porque a Unidade estava fechada (p=0,04) ou pela gravidade do caso (p=0,03). O estudo indica a necessidade de incrementar ações de vigilância às hospitalizações por CSAA, que ocorrem com maior freqüência nos meses de inverno, às crianças de um a nove anos, por apresentarem-se mais vulneráveis à hospitalização por essas condições, e às reinternações, não reduzidas nos últimos quatro anos.

CIHI Survey: Variations in Canadian Rates of Hospitalization for Ambulatory Care Sensitive Conditions

M any chronic conditions, such as diabetes or asthma, can be successfully managed in the community. Appropriate screening, ongoing monitoring, prescribing of medications, providing patient education and other supportive measures that help keep these conditions under control are provided in primary healthcare settings. However, sometimes people with such conditions require hospitalization. Although not all admissions for these conditions are avoidable, timely and effective ambulatory care can potentially reduce the risk of hospitalization by possibly preventing or controlling the onset of an illness or condition or by managing the chronic condition (World Health Organization 2005). These conditions are often referred to as ambulatory care sensitive conditions (ACSC). The conditions used to define ACSC in this analysis include angina, asthma, chronic obstructive pulmonary disorder (COPD), diabetes, grand mal status and other epileptic convulsions, heart failure and pulmonary edema and hypertension (Canadian Institute for Health Information 2008). This is based on an adaptation of the widely used definition of ACSC by Billings et al. (1993). Research shows that variations in ACSC hospitalization rates may be related to factors such as differences in access to and quality of primary healthcare (Ansari et al. 2006; Caminal et al. 2004). They may also be due to differences in communityor hospital-based practice patterns or other factors.

The Effects of Outpatient Management on Hospitalization for Ambulatory Care Sensitive Conditions Associated with Diabetes Mellitus

Ambulatory care sensitive conditions (ACSC) related to diabetes mellitus can potentially be prevented by good quality outpatient care. The purpose of this study was to evaluate which characteristics of ambulatory patients with diabetes were associated with ACSC hospitalizations. Retrospective chart review of 65 adults with an ACSC diabetes-related hospitalization, and 130 controls with diabetes without ACSC hospitalizations. The primary outcome measure was the difference in hemoglobin A1c between groups. Patients with an ACSC hospitalization had poorer glucose control (mean A1c 9.24 versus 7.68, P < 0.001), but there was no difference in blood pressure or lipid control. Prevention of diabetes-related hospitalizations related more closely to glycemic control, rather than other important aspects of comprehensive care.

Do Public Health Clinics Reduce Rehospitalizations?: The Urban Diabetes Study

Safety-net health clinics have been shown to reduce hospitalizations for ambulatory care-sensitive conditions. Their impact on rehospitalization after hospital discharge is unknown. We hypothesized that use of publicly-funded safety-net health clinics would reduce rates of rehospitalization among patients with diabetes. We expected this effect to be most evident among the most vulnerable patients. Linking data from the Philadelphia Health Care Centers (HCCs) with statewide hospital discharge data for 1994-2001 for patients with diabetes, we found that patients enrolled in the HCCs prior to hospitalization were rehospitalized 22% of the time, the same rate as other Philadelphians. Among those at higher risk of rehospitalization because pre-existing diabetes was not noted in hospital records, odds of rehospitalization were reduced by 24% for HCC patients. Given that patients in the HCCs are overwhelmingly poor and uninsured or underinsured, these findings suggest that access to primary care through the HCCs may have a protective effect against the poor health outcomes typically associated with lower socioeconomic status. Enrollment in publicly-funded safety-net health clinics may have prevented rehospitalizations for some vulnerable patients with diabetes.

Preventable Hospitalizations Among Children in California Counties After Child Health Insurance Expansion Initiatives

California has expanded health insurance to children in low- and middle-income families. Currently, Children's Health Initiatives (CHIs) have been developed in 26 counties to supplement Medi-Cal and Healthy Families (SCHIP). Yet, as coverage expands, we know little about the impact of these programs on child health outcomes. Child hospitalizations for ambulatory care sensitive conditions (ACSC) is a widely adopted measure of health outcomes. We compare rates of total ACSC hospitalizations among children ages 0-18 years in 9 operational CHI counties prior to CHI implementation to rates after the CHIs became operational. As a comparison group, we stratify the analyses by family income level and compare children in lower-income to higher-income families. Between 2000 and 2005, there were 281,000 total preventable hospital pediatric admissions. After adjusting for the effects of time and county, the rate of ACSC hospitalizations was 19% lower postimplementation of CHIs versus preimplementation for children of lower-income families (rate ratio of 0.81, P = 0.0001), but not for children of higher-income families (rate ratio of 0.99, P = 0.93).We estimate that 6324 ACSC hospitalizations may have already been prevented in existing CHI counties after implementation, saving about $6.7 million over the 6 years, assuming $7000 per child hospitalization. With health insurance coverage available for all children, and families financially able to connect with an ongoing source of primary care, some of the potential benefits of reduced ACSC hospitalizations may help to offset premium costs associated with assuring that all children have coverage.

Waiting times and hospitalizations for ambulatory care sensitive conditions

Long waits for health care are hypothesized to cause negative health outcomes due to delays in diagnosis and treatment. This study uses administrative data to examine the relationship between time spent waiting for outpatient care and the risk of hospitalization for an ambulatory care sensitive condition (ACSC). Data on the number of days until the next available appointment were extracted from Veterans Affairs (VA) medical centers. Two methodological issues arose. First, the simultaneous determination of individual health status and wait times due to medical triage was overcome by developing an exogenous wait time measure. Second, selection bias due to unobserved case mix differences was minimized by separating in time the sample selection period from the period when wait times and outcomes were measured. Exogenous facility-level wait time was the main variable of interest in a fixed effects stacked heteroskedastic probit regression model that predicted the probability of ACSC hospitalization in each month of a six-month period. There was a significant and positive relationship between facility-level wait times and the probability of experiencing an ACSC hospitalization, especially for facility-level wait times of 29 days or more. Further research is needed to replicate these findings in other populations and among those with different clinical histories. As well, policymakers and researchers need an improved understanding of the causes of long wait times and interventions to decrease wait times.