Prevention Quality Indicators Research Articles

Assessing primary healthcare quality through avoidable hospitalizations: a systematic review

Abstract Background Avoidable hospitalization (AH) for ambulatory care sensitive conditions (ACSC) has been widely used as a measure of the performance of primary health care. However, the lack of a standardized definition of these conditions and the absence of conclusive evidence regarding their efficacy across diverse healthcare settings remain significant challenges. This review aims to systematically identify and synthesize the utilization of AH for ACSCs as a metric for evaluating the quality of primary healthcare (PHC) and factors influencing such quality. Methods We conducted a systematic search for peer-reviewed studies on 3 electronic databases. Studies that used AH for ACSCs to investigate the quality of PHC were included. The following characteristics were extracted: study design, ACSCs definition, AH rates, intervention if applicable, PHC and or patients’ characteristics associated to AH rates, such as accessibility, continuity of care, demographics, socio-economic status, and comorbidities. Results 73 relevant articles were identified, published between 1994 and 2023 and mostly in USA. Preliminary findings based on 56 articles indicate that the majority (48.2%) employed the list of ACSCs from the AHRQ (i.e. the prevention quality indicators) (48.2%). Meanwhile, 12 studies (17.9%) used lists developed or modified by the authors, and another 7 (12.5%) adopted lists previously utilized in other research. Studies conducted in Brazil, Canada and USA employed lists issued by relevant national institutions. Conclusions Although preliminary, these findings highlight two main trends. Firstly, in countries where health authorities have established a standardized set of ACSCs, a notable uniformity is observed. Conversely, in the absence of such standards, variability in defining these conditions is likely to increase. This variation could hinder the comparability across different Primary Health Care (PHC) service organizations and affect the analysis of care quality. Key messages • Most studies used established indicators for the measuring of primary healthcare quality. • Diverse ACSC definitions across countries impair the generalizability of healthcare quality analysis.

Avoidable Hospitalizations in the Military Health System, Fiscal Years 2018-2019.

Ongoing health reforms in the Military Health System (MHS) are expected to shift locations of ambulatory care for up to 1.9 million beneficiaries. We sought to model the impact of this policy by determining potentially avoidable hospitalizations in the MHS based on different primary care settings. We used the MHS Data Repository to conduct a retrospective cross-sectional study of TRICARE Prime and Prime Plus beneficiaries aged 18 to 64 years during fiscal years 2018-2019. Crude and adjusted risk ratios for each Agency for Healthcare Research and Quality prevention quality indicator based on primary care setting were calcualated to determine the total probability of admission for any of the Agency for Healthcare Research and Quality prevention indicators. We identified a total of 260,690 hospital admissions by patients in the MHS with a designated primary care manager (PCM) from fiscal year 2018 to 2019. Of the total admissions, 11,067 (4.25%) were for Agency for Healthcare Research and Quality prevention quality indicators, 3.63% by direct care PCM at a military treatment facility, and 0.61% by a civilian private sector PCM. Risk of admission was lower for private sector PCMs for urinary tract infection, hypertension, perforated appendix, and angina without the procedure. We did not observe a statistically significant adjusted odds ratio of admission in patients managed by private sector PCMs (1.04 adjusted odds ratio; 95% CI, 0.97-1.11). Our findings indicate no difference in the likelihood of avoidable hospitalizations for beneficiaries with a private sector PCM when looking at all conditions together. Patients with a private sector PCM are protected against hospitalization for several conditions. Our findings indicate no adverse impact on avoidable hospitalizations for beneficiaries transitioned to private sector care from direct care.

Quality assurance using quality indicators for prevention and early detection of cervical cancer in certified gynaecological dysplasia units and consultancies

PurposeCervical cancer is the fourth most common cancer in women worldwide. A successful screening concept for cervical cancer reduces the incidence and mortality of cervical cancer. Quality indicators (QIs) derived from the screening guidelines for cervical cancer and used by the certified dysplasia units and dysplasia consultancies are evaluated in this paper. The aim of this paper is to present the current data from the annual reports of these units and consultancies.MethodsThe results of the basic data and indicators for the audit year 2022 in the gynaecological dysplasia consultancies and units are presented. In 2022, 84 dysplasia consultancies and 42 units were audited. 40 units and 84 consultancies are included in the annual report. QI outcomes for patients treated in certified dysplasia units and dysplasia consultancies are analysed. Median, overall proportion, and standard deviation were calculated for each QI.ResultsThe indicator year 2021 was analysed, which was audited in 2022 and evaluated in 2023. A total of nine QIs were analysed. Most target goals were met by the 84 certified dysplasia consultancies and by the 40 dysplasia units. The QIs evaluated are implemented to a very high degree. The targets for the three QIs were achieved by both the dysplasia consultancies and the units in at least 95% of the certified centres (QI 1: 100%, QI 2: 95%, QI 3: 100%; QI 1: 100%, QI 2: 97%, QI 3: 100%, respectively). The presentation of patients to the tumour board by the consultancies/units is working; the units are attending the tumour board more regularly than in previous years. Where the target was not met, the auditors issued deviations or reduced the duration of the certificate. The cases are discussed intensively in the sense of an individual case analysis and with the determination of measures on-site.ConclusionsThe targets for the various indicators were largely met by the dysplasia consultancies and units in the 2022 audit year. The certification of gynaecological dysplasia consultancies/units which have to cooperate with certified gynaecological cancer centres, has for the first time ensured the continuity of healthcare from prevention and early diagnosis to treatment of gynaecological cancers.

Subgroups of High-Cost Patients and Their Preventable Inpatient Cost in Rural China.

High-cost patients account for most healthcare costs and are highly heterogeneous. This study aims to classify high-cost patients into clinically homogeneous subgroups, describe healthcare utilization patterns of subgroups, and identify subgroups with relatively high preventable inpatient cost (PIC) in rural China. A population-based retrospective study was performed using claims data in Xi county, Henan province. 32 108 high-cost patients, representing the top 10% of individuals with the highest total spending, were identified. A density-based clustering algorithm combined with expert opinions were used to group high-cost patients. Healthcare utilization (including admissions, length of stay, and outpatient visits) and spending characteristics (including total spending, and the proportion of PIC, inpatient and out-of-pocket spending on total spending) were described among subgroups. PIC was calculated based on potentially preventable hospitalizations (PPHs) which were identified according to the Agency for Healthcare Research and Quality Prevention Quality Indicators algorithm. High-cost patients were more likely to be older (Mean=51.87, SD=22.28), male (49.03%) and from poverty-stricken families (37.67%) than non-high-cost patients, with 2.49 (SD=2.47) admissions and 3.25 (SD=4.52) outpatient visits annually. Fourteen subgroups of high-cost patients were identified: chronic disease, non-trauma diseases which need surgery, female disease, cancer, eye disease, respiratory infection/inflammation, skin disease, fracture, liver disease, vertigo syndrome and cerebral infarction, mental disease, arthritis, renal failure, and other neurological disorders. The annual admissions ranged from 1.83 (SD=1.23, fracture) to 12.21 (SD=9.26, renal failure), and the average length of stay ranged from 6.61 (SD=10.00, eye disease) to 32.11 (SD=28.78, mental disease) days among subgroups. The chronic disease subgroup showed the largest proportion of PIC on total spending (10.57%). High-cost patients were classified into 14 clinically distinct subgroups which had different healthcare utilization and spending characteristics. Different targeted strategies may be needed for subgroups to reduce preventable hospitalizations. Priority should be given to high-cost patients with chronic diseases.

Segregated Patterns of Hospital Care Delivery and Health Outcomes

Residential segregation has been shown to be a root cause of racial inequities in health outcomes, yet little is known about current patterns of racial segregation in where patients receive hospital care or whether hospital segregation is associated with health outcomes. Filling this knowledge gap is critical to implementing policies that improve racial equity in health care. To characterize contemporary patterns of racial segregation in hospital care delivery, identify market-level correlates, and determine the association between hospital segregation and health outcomes. This cross-sectional study of US hospital referral regions (HRRs) used 2018 Medicare claims, American Community Survey, and Agency for Healthcare Research and Quality Social Determinants of Health data. Hospitalization patterns for all non-Hispanic Black or non-Hispanic White Medicare fee-for-service beneficiaries with at least 1 inpatient hospitalization in an eligible hospital were evaluated for hospital segregation and associated health outcomes at the HRR level. The data analysis was performed between August 10, 2022, and September 6, 2023. Dissimilarity index and isolation index for HRRs. Health outcomes were measured using Prevention Quality Indicator (PQI) acute and chronic composites per 100 000 Medicare beneficiaries, and total deaths related to heart disease and stroke per 100 000 residents were calculated for individuals aged 74 years or younger. Correlation coefficients were used to compare residential and hospital dissimilarity and residential and hospital isolation. Linear regression was used to examine the association between hospital segregation and health outcomes. This study included 280 HRRs containing data for 4386 short-term acute care and critical access hospitals. Black and White patients tended to receive care at different hospitals, with a mean (SD) dissimilarity index of 23 (11) and mean (SD) isolation index of 13 (13), indicating substantial variation in segregation across HRRs. Hospital segregation was correlated with residential segregation (correlation coefficients, 0.58 and 0.90 for dissimilarity and isolation, respectively). For Black patients, a 1-SD increase in the hospital isolation index was associated with 204 (95% CI, 154-254) more acute PQI hospitalizations per 100 000 Medicare beneficiaries (28% increase from the median), 684 (95% CI, 488-880) more chronic PQI hospitalizations per 100 000 Medicare beneficiaries (15% increase), and 6 (95% CI, 2-9) additional deaths per 100 000 residents (6% increase) compared with 68 (95% CI, 24-113; 6% increase), 202 (95% CI, 131-274; 8% increase), and 2 (95% CI, 0 to 4; 3% increase), respectively, for White patients. This cross-sectional study found that higher segregation of hospital care was associated with poorer health outcomes for both Black and White Medicare beneficiaries, with significantly greater negative health outcomes for Black populations, supporting racial segregation as a root cause of health disparities. Policymakers and clinical leaders could address this important public health issue through payment reform efforts and expansion of health insurance coverage, in addition to supporting upstream efforts to reduce racial segregation in hospital care and residential settings.

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

PSUN303 Nationwide Geospatial Analysis of Hospitalization in Diabetes Mellitus Complications

Abstract Diabetes mellitus and complications associated with the disease represent a significant source of morbidity within the United States. Substantial public health efforts have been devoted to understanding the factors that underlie poor outcomes in diabetes. The purpose of this work is to (1) determine whether there exist statistically significant geospatial disparities in the relative rate of diabetic complications in Medicare patients throughout the United States, and (2) if these exist, assess the socioeconomic, cultural, and medical attributes that distinguish communities delineated by these variations. This work utilized multiple public databases, including National Plan and Provider Enumeration System (NPPES), US Department of Agriculture (USDA), US Census, and Center for Medicare Services (CMS) data. Datasets were combined on a county level to quantify 18 socioeconomic, 22 health, and 4 diabetic management attributes of 3061 total counties in the contiguous United States. CMS Prevention Quality Indicators (PQI) #1 (Diabetes Short-Term Complications Admission Rate), #3 (Diabetes Long-Term Complications Admission Rate), and #16 (Lower-Extremity Amputation Among Patients with Diabetes Rate) were used as the main indicators of county-level diabetic control, along with the total number of practicing endocrinologists. These variables were scaled to the number of Medicare members with diabetes in each county. All variables were for the latest available year, 2019, with the exception of the number of practicing endocrinologists (from December 2021). The synthesized database was then exported to GeoDa, a geospatial analysis program, where statistically significant (p &amp;lt; 0.05) diabetes complication spatial hotspots, coldspots, and outliers were identified using Moran's I on a national level. ANOVA was then conducted across all Moran's I groupings with a two-tailed t-test between hotspot and coldspot groupings to identify what socioeconomic, health, and diabetic management attributes were statistically significant between complication geostructures. Geospatial visualization revealed an expansive hotspot cluster in the normalized diabetes long-term complication admission rate that encompassed the East Coast and included portions of Florida and Texas (p &amp;lt; 0.05). Conversely, an expansive coldspot cluster encompassed much of the West and Great Plains region. Similar geospatial patterns were observed in the short-term complication admission rate, with the caveat of a new hotspot cluster that encompassed California and the West Coast (p &amp;lt; 0.05). ANOVA using the identified clusters as groupings revealed differences between hotspot and coldspot clusters: Hotspots tended to have greater Hispanic (6.7% to 1.8%) and Black (10.9% to 0.6%) representation compared to coldspots. They tended to have greater population density (2877 to 124 persons/sq. mile). Hotspots also tended to have more endocrinologists per capita (3.0 to 0.87) than coldspots. Variables of interest that did not appear to differ included the percent in poverty and the percent uninsured. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Association between socio-economic deprivation and AHRQ composite indicator during pandemic

Abstract Background The Agency for Healthcare Research and Quality (AHRQ) identifies preventable hospitalizations as proxy of potentially low-quality of care. Previous studies showed as socio-economic status was associated to poor diseases outcomes and to the performance of health services. Recently a particular attention was focused on the effect of the pandemic on this context. The aim of this research is to analyze the association between poor quality of primary care and socio-economic status before and during the pandemic. Methods A retrospective observational study was conducted in Abruzzo Region, Italy. Hospital discharge records (HDR) of two different periods were selected: from April to December for 2019 and 2020. The aggregate Prevention Quality Indicator 90 (PQI-90) has been coded according to the indications of the AHRQ. The Italian socioeconomic deprivation index (DI), divided in quintiles (from 1st less deprived to the 5th most deprived) was attributed to all patient, based on the municipality of residence. A multivariate logistic regression model was performed to evaluate the association between PQI-90 and DI. Results Totally were analyzed 253,063 HDR, of which 14,845 attributable to the PQI-90. By correcting for gender, age and number of comorbidities, the DI was not associated with the PQI-90 during 2019. During 2020 the PQI-90 was associated to 4th DI quintile (aOR 1.19;95%CI 1.09-1.30) and 5th DI quintile (aOR 1.13; 95%CI 1.03-1.23), compared to the 1st quintile. Conclusions The impact of the pandemic on primary care has been substantial. Compared to the pre-pandemic era, during the pandemic, an association between potentially poor quality of care and the most disadvantaged socio-economic areas has been shown in Abruzzo. This evidence must be an interesting starting point for health planning in order to fight against inequalities in health services access. Key messages • The reduction in the primary care quality during pandemic caused potentially preventable hospitalizations and it was associated to socioeconomic deprivation. • The analysis of hospital admission linked to context indicators such as the deprivation index, can be a useful tool for the policy maker in order to reduce healthcare inequalities.

Effects of utilization management on health outcomes: evidence from urinary tract infections and community-acquired pneumonia

ABSTRACT Background Utilization management policies are pervasive in the Medicare Part D program. We assess the effect of utilization management restrictions in the Medicare Part D program on the quality of care in two clinical areas – community-acquired pneumonia (CAP) and urinary tract infections (UTI). Methods In this study, we identified new cases of CAP and UTI from Medicare claims data from 2010 to 2016. We assessed the relationship between exposure to utilization management for antibiotic medications suitable for treating these conditions and adverse health outcomes, based on the Agency for Healthcare Research and Quality prevention quality indicators. Results We identified 147,526 cases of CAP and 632,407 UTI cases in our data. In these samples, the adverse event rate varied from 3.6 to 5.7%. The probability of an adverse event increased by 0.75 (p = 0.061) percentage points for each ten percentage point increase in exposure to quantity limits (one form of utilization management) among people with CAP. There was no relationship between utilization management and adverse events in the UTI cohort. Conclusions In some circumstances, exposure to utilization management policies–particularly quantity limits–may adversely affect health.

A Scoping Review of Non-Pharmacological, Non-Surgical Secondary Prevention Strategies in Ischaemic Stroke and TIA in National Stroke Guidelines and Clinical Audit Documents.

The Stroke Action Plan for Europe (2018–2030) calls for national-level secondary prevention plans that address lifestyle, in addition to prevention medications and surgical interventions. This scoping review examines national stroke care guideline and audit documents across WHO regions to identify non-pharmacological, non-surgical stroke secondary prevention recommendations and associated performance indicators. Using a snowballing methodology, 27 guideline documents met the inclusion criteria. Sixteen (59%) detailed, non-pharmacological, non-surgical stroke secondary prevention-addressing known, modifiable population attributable risk factors, of physical inactivity (N = 11), smoking (N = 11), unsafe alcohol consumption (N = 10), diet (N = 8), weight (N = 5), stress (N = 4) and depression (N = 2). Strategies recommended to address these risk factors were: assessment of stroke risk/risk factors (N = 4); provision of advice and information on reducing lifestyle related risk (N = 16); education and counselling for lifestyle behaviour change (N = 8) and onward referral for specialist management of risk (N = 4). Of the nine stroke audits/registries identified, only three (33%) included non-pharmacological, non-surgical quality indicators of documented provision of advice or information on the following: general lifestyle (N = 2); smoking cessation for current smokers (N = 2); reduction in alcohol consumption, where relevant (N = 1), exercise participation (N = 1) and diet (N = 1). Preventive quality indicators addressing the management of weight, stress or depression were absent. This review highlights current gaps in optimal stroke secondary prevention recommendations and their implementation.

Trends in quality of primary care in the United States, 2007\u20132016

During the past decade, many reforms were proposed and implemented for improving primary care in the US. This study assessed improvements in quality of primary care, using a nationally representative database. We conducted a retrospective trend analysis of National Inpatient Sample data (2007–2016). The quality of primary care was assessed using Prevention Quality Indicators (PQIs), which consist of 13 sets of preventable hospitalization conditions. PQI hospitalization decreased from 154,565 to 151,168 per million hospitalizations during the study period (relative decrease, 2.2%; P = 0.041). Age-adjusted hospitalization rate increased for diabetes short-term complications (relative increase, 46.9%; P < 0.001) and lower-extremity amputations (relative increase, 15.1%; P = 0.035). Age stratified trends showed that hospitalization rates decreased significantly in all age-groups for diabetes short-term complications. For lower-extremity amputations, hospitalization rates increased significantly in younger age groups and decreased significantly in the older age groups. All other PQIs showed either decreasing or no change in trends. Adults aged 18–64 years should be the focus for future prevention attempts for diabetes complications. Identifying and acting on the factors responsible for these changes could help in reversing the concerning trends observed in this study. Existing strategies should focus on improving access to diabetes care and self-management.

Disparities in diabetes-related avoidable hospitalization among diabetes patients with disability using a nationwide cohort study

Diabetes is an ambulatory care sensitive condition that quality of care can prevent complications development and hospitalization needs. However, diabetes patients with disability face greater challenges with receiving quality diabetes care than those without disabilities. This study examined diabetes-related avoidable hospitalizations (DRAH) focusing on the association with disability. We used nationally representative health insurance cohort data from 2002 to 2013. The study population is people who were newly diagnosed with type 2 diabetes. We measured the cumulated number of DRAH using the Prevention Quality Indicators (PQIs). The variables of interest were disability severity and type. We performed a recurrent events analysis using Cox proportional hazard regression model. Among 49,410 type 2 diabetes patients, 12,231 (24.8%) experienced DRAHs at least once during the follow-up period. Among the total population, 5924 (12.0%) diabetes patients were registered as disabled. The findings report that disability severity was significantly associated with higher risks for DRAH, where severely disabled diabetes patients showed the highest hazard ratio of 2.24 (95% CI 1.80–2.79). Among three DRAH indicators, severely disabled diabetes patients showed increased risks for long-term (AHR 2.21, 95% CI 1.89–2.60) and uncontrolled (AHR 2.28, 95% CI 1.80–2.88) DRAH. In addition, intellectual (AHR 5.52, 95% CI 3.78–8.05) and mental (AHR 3.97, 95% CI 2.29–6.89) disability showed higher risks than other types of disability. In conclusion, diabetes patients with disability are at higher risk for DRAH compared to those without disabilities, and those with intellectual and mental disabilities were more likely to experience DRAH compared to those with physical or other types of disability. These findings call for action to find the more appropriate interventions to improve targeted diabetes primary care for patients with disability. Further research is needed to better understand determinants of increasing risks of DRAH.

National Hospitalization Trends and the Role of Preventable Hospitalizations among Centenarians in the United States (2000-2009).

Increases in life expectancy mean that an unprecedented number of individuals are reaching centenarian status, often with complex health concerns. We analyzed nationally representative hospital admissions data (200–2009) from the National Inpatient Study (NIS) for 52,618 centenarians (aged 100–115 years, mean age 101.4). We predicted length of stay (LOS) via negative binomial models and total inflation adjusted costs via fixed effects regression analysis informed by descriptive data. We also identified hospitalizations due to ambulatory care-sensitive conditions defined by AHRQ Prevention Quality Indicators. Mean LOS decreased from 6.1 to 5.1 days, while over the same time period the mean total adjusted charges rose from USD 13,373 to USD 25,026 in 2009 dollars. Black, Hispanic, Asian, or other race centenarians had higher cost stays compared to White, but only Black and Hispanic centenarians had significantly greater mean length of stay. Comorbidities predicted greater length of stay and higher costs. Centenarians admitted on weekends had higher costs but shorter length of stay. In total, 29.4% of total costs were due to potentially preventable hospitalizations for total charges (2000–2009) of USD 341.8M in 2009 dollars. Centenarian hospitalizations cost significantly more than hospitalization for any other group of elderly in the U.S.

Regional Economic Conditions and Preventable Hospitalization Among Older Patients With Diabetes.

The aim was to explore the relationship between changes in regional economic conditions and quality of care-preventable hospitalization or death among older patients with diabetes at Veterans Health Administration (VHA), safety-net system for veterans. VHA patients aged 65 years and older with a diabetes diagnosis between July 2012 and June 2014, who had at least 1 primary care visit in the past year. County-level and state-level public data were used to characterize regional health insurance coverage and affluence surrounding the VHA facilities. Each patient was associated with a VHA facility and its corresponding regional market variables, and followed up to 48 months or until they experienced diabetes-related Prevention Quality Indicators or death. Discrete-time Cox proportional hazards models estimated that changes in regional market variables characterizing regional health insurance coverage and affluence were significant factors associated with preventable hospitalization or death. All regional market variables were combined into a demand index, where 1 SD decrease in the demand index was associated with a 2.0-point increase in predicted survival for an average patient at an average VHA facility. For comparison, a 1 SD increase in primary care capacity was associated with 4.7-point increase. Downturns in regional economic conditions could increase demand for VHA care and raise the risk of diabetes-related preventable hospitalization or death among older VHA patients diagnosed with diabetes. Safety-net hospitals may be unfairly penalized for lower quality of care when experiencing higher demand for care because of an economic downturn.

The Association of Demographic, Socioeconomic, and Geographic Factors with Potentially Preventable Emergency Department Utilization.

IntroductionPrevention quality indicators (PQI) are a set of measures used to characterize healthcare utilization for conditions identified as being potentially preventable with high quality ambulatory care. These indicators have recently been adapted for emergency department (ED) patient presentations. In this study the authors sought to identify opportunities to potentially prevent emergency conditions and to strengthen systems of ambulatory care by analyzing patterns of ED utilization for PQI conditions.MethodsUsing multivariable logistic regression, the authors analyzed the relationship of patient demographics and neighborhood-level socioeconomic indicators with ED utilization for PQI conditions based on ED visits at an urban, academic medical center in 2017. We also used multilevel modeling to assess the contribution of these variables to neighborhood-level variation in the likelihood of an ED visit for a PQI condition.ResultsOf the included 98,522 visits, 17.5% were categorized as potentially preventable based on the ED PQI definition. On multivariate analysis, age < 18 years, Black race, and Medicare insurance had the strongest positive associations with PQI visits, with adjusted odds ratios (aOR) of 1.41 (95% confidence interval [CI], 1.29, 1.56), 1.40 (95% CI, 1.22, 1.61), and 1.40 (95% CI, 1.28, 1.54), respectively. All included neighborhood-level socioeconomic variables were significantly associated with PQI visit likelihood on univariable analysis; however; only level of education attainment and private car ownership remained significantly associated in the multivariable model, with aOR of 1.13 (95% CI, 1.10, 1.17) and 0.96 (95% CI, 0.93, 0.99) per quartile increase, respectively. This multilevel model demonstrated significant variation in PQI visit likelihood attributable to neighborhood, with interclass correlation decreasing from 5.92% (95% CI, 5.20, 6.73) in our unadjusted model to 4.12% (95% CI, 3.47, 4.87) in our fully adjusted model and median OR similarly decreasing from 1.54 to 1.43.ConclusionDemographic and local socioeconomic factors were significantly associated with ED utilization for PQI conditions. Future public health efforts can bolster efforts to target underlying social drivers of health and support access to primary care for patients who are Black, Latino, pediatric, or Medicare-dependent to potentially prevent emergency conditions (and the need for emergency care). Further research is needed to explore other factors beyond demographics and socioeconomic characteristics driving spatial variation in ED PQI visit likelihood.

European Society of Cardiology Quality Indicators for Cardiovascular Disease Prevention: developed by the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with the European Association for Preventive Cardiology of the European Society of Cardiology.

To develop a set of quality indicators (QIs) for the evaluation of the care and outcomes for atherosclerotic cardiovascular disease (ASCVD) prevention. The Quality Indicator Committee of the European Society of Cardiology (ESC) formed the Working Group for Cardiovascular Disease Prevention Quality Indicators in collaboration with Task Force members of the 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice and the European Association of Preventive Cardiology (EAPC). We followed the ESC methodology for QI development, which involved (i) the identification of the key domains of care for ASCVD prevention by constructing a conceptual framework of care, (ii) the development of candidate QIs by conducting a systematic review of the literature, (iii) the selection of the final set of QIs using a modified Delphi method, and (iv) the evaluation of the feasibility of the developed QIs. In total, 17 main and 14 secondary QIs were selected across six domains of care for ASCVD prevention: (i) structural framework, (ii) risk assessment, (iii) care for people at risk for ASCVD, (iv) care for patients with established ASCVD, (v) patient education and experience, and (vi) outcomes. We present the 2021 ESC QIs for Cardiovascular Disease Prevention, which have been co-constructed with EAPC using the ESC methodology for QI development. These indicators are supported by evidence from the literature, underpinned by expert consensus and aligned with the 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice to offer a mechanism for the evaluation of ASCVD prevention care and outcomes.

Abstract P178: Social Determinants Of Health And Preventable Hospitalization For Hypertension

Introduction: Social determinants of health (SDH) can have a significant impact on the risk of hypertension related hospitalization. Understanding the drivers of potentially preventable hospitalizations for hypertension improves health outcomes and reduce associated costs. Identifying place and associated SDH has implications for tailored interventions to address disparities for high burden population for preventable hypertension hospitalization as hypertension and associated cardiovascular disease. Methods: County level preventable hospitalization rates for hypertension for Virginia was obtained using prevention quality indicators published by the Agency for Healthcare Research and Quality. The Health Opportunity Index (HOI), developed by the Virginia Department of Health to identify vulnerable populations is a multivariate tool that uses complex SDH indicators of a community and comprises of 13 indices - affordability, income inequality, Townsend/Material deprivation, job participation, employment access, education, air quality, segregation, food accessibility, population density, population churning, walkability, and access to care. Principal component analysis was used to develop the composite HOI and further aggregated into simple quintiles at the county level. Step-wise multiple regression analysis was performed to explore SDH and preventable hospitalization for hypertension. Results: Material deprivation index ( r = -.44), affordability index ( r = -.42) and air quality index ( r = -.23) were found to be significantly associated with preventable hospitalization rate for hypertension. Together the model accounted for 23% of the variability in the preventable hypertension hospitalization rate ( p &gt; 0.05). Conclusions: Findings indicate that neighborhoods that spend most on housing and transportation and that are materially deprived of goods, services, amenities and resources and physical environment have higher rates of preventable hospitalization for hypertension. Areas with higher air pollution may result in hypertension. Addressing these disparities by targeted approach is one possible approach to reducing the burden of preventable hospitalization for hypertension in Virginia.

Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort

This study sought to describe the cost of hospital care for ambulatory care-sensitive conditions (ACSCs) and to identify independent predictors of high-cost hospital encounters related to an ACSC among an urban community health center cohort. The authors conducted a retrospective cohort study of individuals engaged in care in a large, multisite community health center in New Haven, Connecticut, with any Medicaid claims between June 1, 2018 and March 31, 2020. Prevention Quality Indicators of the Agency for Healthcare Research and Quality were used to identify ACSCs. The primary outcome was a high-cost episode of care for an ACSC (in the top quartile within a 7-day period). Multivariable logistic regression was used to identify independent predictors of high-cost episodes by ACSCs among sociodemographic and clinical variables as covariates. Among 8019 included individuals, a total of 751 episodes of hospital care involving ACSCs were identified. The median episode cost was $793, with the highest median cost of care related to heart failure ($4992), followed by diabetes ($1162), and chronic obstructive pulmonary disease ($1141). In adjusted analyses, male gender (P < 0.01), increasing age (P = 0.02), and ACSC type (P < 0.01) were associated with higher costs of care; race/ethnicity was not. Community health centers in urban settings seeking to reduce the cost of care of potentially preventable hospitalizations may target disease-/condition-specific groups, particularly individuals of increasing age with congestive heart failure and diabetes mellitus. These findings may inform return-on-investment calculations for care coordination and other enabling services programming.

The Burden of Diabetes-Related Preventable Hospitalization: 11-Year Trend and Associated Factors in a Region of Southern Italy.

(1) Introduction: Diabetes care is complex and delivered by different care providers in different settings across the healthcare system. Better coordination through all levels of care can lead to better outcomes and fewer hospitalizations. Prevention quality indicators (PQIs) for diabetes allow us to monitor diabetes-related avoidable admissions. The aim of this research is to assess the trend of diabetes-related preventable hospitalizations and associated risk factors in a southern Italian region. (2) Methods: The study considered all hospital admissions performed from 2008 to 2018 in the Abruzzo region, Southern Italy. Data were collected from hospital discharge records. Four different indicators were evaluated as follows: short-term complications (PQI-01), long-term complications (PQI-03), uncontrolled diabetes (PQI-14) and lower-extremity amputations (PQI-16). Joinpoint models were used to evaluate the time trends of standardized rates and the average annual percent change (AAPC). (3) Results: During study period, 8660 DRPH were performed: 1298 among PQI-01, 3217 among PQI-03, 1975 among PQI-14 and 2170 among PQI-16. During the study period, PQI-01and PQI-04 showed decreasing trends. An increasing trend was showed by PQI-16. (4) Conclusions: During an 11-year period, admissions for short-term diabetes complications and for uncontrolled diabetes significantly decreased. The use of standardized tools as PQIs can help the evaluation of healthcare providers in developing preventive strategy.

Portuguese Primary Healthcare and Prevention Quality Indicators for Diabetes Mellitus - A Data Envelopment Analysis.

Diabetes mellitus (DM) is a worldwide public health priority. The increasing prevalence and the budget constraints force to have effective healthcare, especially at the primary healthcare (PHC) level. We aim to assess primary care efficiency considering the best use of human resources to produce optimal diabetes care in terms of prevention quality indicators (PQIs) rates across national ACES (health centre groupings). We conducted a two-stage data envelopment analysis (DEA) to assess the technical efficiency of 54 Portuguese primary care health centre groupings for the 2016-2017 biennium. In the first stage, efficiency scores were obtained through five output-oriented DEA models under vector return to scale (VRS) assumption, using three input variables representing key primary care human resources and one output representing each one of the five PQIs related to diabetes. In the second stage, Tobit regression models were estimated to assess the determinants of primary care efficiency in diabetes care. A total of 13 ACES reached the efficiency frontier. Better managing human resources could reduce PQI rates by 52.3% in 2016 and 49.1% in 2017. Higher proportion of patients under 65 years old and better controlled with a hemoglobin A1c (HbA1c) ≤6.5% were associated with better efficiency in diabetes care, whereas higher prevalence of DM and unemployment worsened hospitalizations rates by diabetes short-term complications and lower-extremity amputation. Inefficiency in DM care was found in most of the primary care settings which can substantially improve the avoidable hospitalization rates by DM using their current level human resources. These findings help to improve diabetes care by targeting human resources at primary care level, which should be integrated into performance assessments considering broader and integrated scopes.