The relationship between avoidable hospitalization and accessibility to primary care: a systematic review

Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis

Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.

Emergency Department Use Following Self-Harm and Suicide Ideation: An Analysis of the Influence of Cultural and/or Linguistic Diversity Using Data From the Self-Harm Monitoring System for Victoria (2012-2019)

Self-harm and suicide ideation are global health concerns, significantly impacting culturally and linguistically diverse (CALD) populations. Emergency departments (EDs) play a role in intervening following such presentations, yet there is limited research focusing on the CALD population's use of these services in Australia. This study aimed to explore patterns in ED use for self-harm and suicide ideation, comparing CALD and non-CALD persons in terms of service use, presentation themes and likelihood of repeat presentations. This was a cross-sectional analysis of data from presentations for self-harm and suicide ideation to the ED of a major metropolitan hospital in Victoria, Australia, from 2012 to 2019. The study used thematic analysis of triage notes, recurrent event analysis and logistic and linear regressions to compare CALD and non-CALD presentations. CALD presentations comprised 1.3% (n = 202) of the total (n = 15 606). CALD presentations were more likely to occur during business hours, less likely to be triaged as urgent and more likely to result in ward admission. Occupation stressors were more common in CALD presentations. A lower likelihood of repeat presentations was observed among CALD persons. The study also highlighted the limitations of current data collection practices in capturing the full spectrum of CALD presentations. This study found variability in the recording of CALD status, warranting further investigation into how data collection in EDs may be improved. Increased ward admission rate and lower likelihood of repeat presentation by CALD persons also indicate that further research is required to understand help-seeking and clinical decision-making in the CALD population.

Potentially avoidable hospitalizations and associated factors among older people in French Guiana using the French National Health Data System

Knowing the prevalence of potentially avoidable hospitalizations (PAHs) and the factors associated with them is essential if preventive action is to be taken. Studies on PAHs mainly concern adults, and very few have been carried out in South America. To the best of our knowledge, there has been no study on PAHs in French Guiana, particularly among older adults. This case-control study aimed to estimate the prevalence of PAHs in the Guianese population aged over 65 and to analyze their associated factors. We used the 2017-2019 data from the French National Health Service database (Système National des Données de Santé). The patients were age- and sex-matched 1 : 3 with controls without any PAH in 2019. Factors associated with PAHs were investigated through two conditional logistic regression models [one including the Charlson comorbidity index (CCI) and one including each comorbidity of the CCI], with calculation of the adjusted odds ratio (aOR) and 95% confidence interval (CI). The PAH incidence was 17.4 per 1000 inhabitants. PAHs represented 6.6% of all hospitalizations (45.6% related to congestive heart failure or hypertension). A higher CCI was associated with PAHs [aOR 2.2 (95% CI: 1.6, 3.0) and aOR 4.8 (95% CI: 2.4, 9.9) for 1-2 and ≥3 comorbidities, respectively, versus 0], as was immigrant health insurance status [aOR 2.3 (95% CI: 1.3, 4.2)]. Connective tissue disease, chronic pulmonary disease, congestive heart failure, diabetes, and peripheral vascular disease were comorbidities associated with an increased risk of PAHs. While the prevention of PAHs among immigrants is probably beyond the reach of the Guianese authorities, primary care and a public health policy geared toward prevention should be put in place for the French Guianese population suffering from cardiovascular disease in order to reduce PAHs.

Avoidable Hospitalizations in Frail Older Adults: The Role of Sociodemographic, Clinical, and Care-Related Factors

OBJECTIVES

This study aims to investigate the relationship between frailty and avoidable hospitalization risk, and the moderating role of sociodemographic, clinical, and care-related factors.

DESIGN

Longitudinal population-based cohort study.

SETTING AND PARTICIPANTS

A total of 3168 community-dwelling individuals, aged ≥60 years, from the Swedish National study on Aging and Care in Kungsholmen (SNAC-K).

METHODS

We operationalized physical frailty using baseline SNAC-K data (2001-2004). In line with the Swedish Board of Health and Welfare and Association of Local Authorities and Regions, avoidable hospitalizations were considered those that could have been prevented through proper and timely outpatient care and identified through the Swedish National Patient Register. Participants were followed from baseline until first avoidable hospitalization, death, drop out, institutionalization, or maximum 12 (median 7.6) years. The association between frailty and avoidable hospitalization was explored through flexible parametric survival models, with stratified analyses to investigate age, gender, education, civil status, multimorbidity, cognitive status, and informal and formal care as potential modifiers.

RESULTS

The adjusted 12-year cumulative incidence of avoidable hospitalization was significantly higher for frail persons (cumulative incidence 33.2%, 95% CI 28.9%-38.1%) than for prefrail (cumulative incidence 26.6%, 95% CI 24.5%-29.0%) and nonfrail (cumulative incidence 25.2%, 95% CI 22.5%-28.3%) individuals. In addition, prefrailty [hazard ratio (HR) 1.21, 95% CI 1.00-1.45] and frailty (HR 1.91, 95% CI 1.47-2.50) were associated with increased avoidable hospitalization hazards. Furthermore, the association between frailty and avoidable hospitalization was stronger in older adults aged <78 years (HR 3.12, 95% CI 1.99-4.91) and those with relatively fewer chronic diseases (HR 3.88, 95% CI 1.95-7.72), whereas provision of formal social care (HR 1.15, 95% CI 0.77-1.72) seemed to act as a buffer.

CONCLUSIONS AND IMPLICATIONS

Our results indicate that older community-dwelling adults with prefrailty and frailty are at increased risk of experiencing avoidable hospitalizations, highlighting a need for better care of these individuals at the outpatient level. Formal social care services and close monitoring of particularly vulnerable subgroups of frail persons may mitigate this risk.

Evaluating the impact of the 2010 Swedish choice reform in primary health care on avoidable hospitalization and socioeconomic inequities: an interrupted time series analysis using register data

BACKGROUND

The Swedish Primary Health Care (PHC) system has, like in other European countries, undergone a gradual transition towards marketization and privatization, most distinctly through a 2010 choice reform. The reform led to an overall but regionally heterogenous expansion of private PHC providers in Sweden, and with evidence also pointing to possible inequities in various aspects of PHC provision. Evidence on the reform's impact on population-level primary health care performance and equity in performance remains scarce. The present study therefore aimed to examine whether the increase in private provision after the reform impacted on population-average rates of avoidable hospitalizations, as well as on corresponding socioeconomic inequities.

METHODS

This register-based study used a multiple-group interrupted time-series design for the study period 2001-2017, with the study population (N = 51 million observations) randomly drawn from the total Swedish population aged 18-85 years. High, medium, and low implementing comparison groups were classified by tertiles of increase in private PHC providers after the reform. PHC performance was measured by avoidable hospitalizations, and socioeconomic position by education and income. Interrupted time series analysis based on individual-level data was used to estimate the reform impact on avoidable hospitalization risk, and on inequities through the Relative Index of Inequality (RII).

RESULTS

All three comparisons groups displayed decreasing risk of avoidable hospitalizations but increasing socioeconomic inequities across the study period. Compared to regions with little change in provision after the reform, regions with large increase in private provision saw a steeper decrease in avoidable hospitalizations after the reform (relative risk (95%): 1.6% (1.1; 2.1)), but at the same time steeper increase in inequities (by education: 2.0% (0.1%; 4.0); by income: 2.2% (-0.1; 4.3)).

CONCLUSIONS

The study suggests that the increase in private health care centers, enabled by the choice reform, contributed to a small improvement when it comes to overall PHC performance, but simultaneously to increased socioeconomic inequities in PHC performance. This duality in the impact of the Swedish reform also reflects the arguments in the European health policy debate on patient choice PHC models, with hopes of improved performance but fears of increased inequities.

Impact of diabetes on mortality and hospitalization after dementia diagnosis: Health insurance claims data analysis

AIM

Japan faces a public health challenge of dementia, further complicated by the increasing complications from diabetes within its rapidly aging population. This study assesses the impact of diabetes on mortality and hospitalization among individuals aged ≥75 years with new dementia diagnoses.

METHODS

We analyzed administrative claims data in Japan from 73 324 individuals aged ≥75 years with dementia, of whom 17% had comorbid diabetes. Dementia and diabetes were identified from the International Classification of Diseases, Tenth Revision codes. We used Kaplan-Meier survival analysis, Cox proportional hazards analysis, and population attributable fractions (PAFs) to evaluate the impact on mortality and hospitalization after dementia diagnosis.

RESULTS

One-year mortality and 1-year hospitalization probabilities in individuals with dementia and diabetes (10.3% and 31.7%, respectively) were higher than those without diabetes (8.3% and 25.4%, respectively). The adjusted hazard ratios for individuals with diabetes, as compared to those without, were 1.126 (95% confidence interval [CI], 1.040-1.220) for mortality and 1.191 (95% CI, 1.140-1.245) for hospitalization. The PAFs from the comorbidity of dementia and diabetes were 2.2% for mortality and 3.1% for hospitalization. Subgroup analysis showed that the PAFs were highest in men aged 75-79 years and women aged 80-84 years for mortality and in individuals aged 75-79 for hospitalization.

CONCLUSION

During the early postdiagnosis period, comorbid diabetes increases mortality and hospitalization risks in older adults with dementia. The variation in disease burden across age groups underscores the need for age-specific health care strategies to manage comorbid diabetes in individuals with dementia. Geriatr Gerontol Int 2024; 24: 773-781.

Barriers and facilitators to screen for and address social needs in primary care practices in Maryland: a qualitative study

Background

Social needs screening can help modify care delivery to meet patient needs and address non-medical barriers to optimal health. However, there is a need to understand how factors that exist at multiple levels of the healthcare ecosystem influence the collection of these data in primary care settings.

Methods

We conducted 20 semi-structured interviews involving healthcare providers and primary care clinic staff who represented 16 primary care practices. Interviews focused on barriers and facilitators to awareness of and assistance for patients' social needs in primary care settings in Maryland. The interviews were coded to abstract themes highlighting barriers and facilitators to conducting social needs screening. The themes were organized through an inductive approach using the socio-ecological model delineating individual-, clinic-, and system-level barriers and facilitators to identifying and addressing patients' social needs.

Results

We identified several individual barriers to awareness, including patient stigma about verbalizing social needs, provider frustration at eliciting needs they were unable to address, and provider unfamiliarity with community-based resources to address social needs. Clinic-level barriers to awareness included limited appointment times and connecting patients to appropriate community-based organizations. System-level barriers to awareness included navigating documentation challenges on the electronic health record.

Conclusions

Overcoming barriers to effective screening for social needs in primary care requires not only practice- and provider-level process change but also an alignment of community resources and advocacy of policies to redistribute community assets to address social needs.

Describing primary care patterns before and during the COVID-19 pandemic across Canada: a quasi-experimental pre-post design cohort study using national practice-based research network data

OBJECTIVE

The objective was to analyse how the pandemic affected primary care access and comprehensiveness in chronic disease management by comparing primary care patterns before and during the early COVID-19 pandemic.

DESIGN

We conducted a quasi-experimental pre-post design cohort study and reported indicators for the 21 months before and after the onset of the COVID-19 pandemic.

SETTING

We used electronic medical record data from primary care clinics enrolled in the Canadian Primary Care Sentinel Surveillance Network from 1 January 2018 to 31 December 2021.

POPULATION

The study population included patients (n=919 928) aged 18 years or older with at least one primary care contact from 12 March 2018 to 12 March 2020, in Canada.

OUTCOME MEASURES

The study indicators included three indicators measuring access to primary care (encounters, blood pressure measurements and lab tests) and three for comprehensiveness (diagnoses, non-COVID-19 vaccines administered and referrals).

RESULTS

67.3% of the cohort was aged ≥40 years, 56.4% were female and 53.5% were from Ontario, Canada. Fewer patients received an encounter during the pandemic (91.5% to 81.5%), while the median (IQR) number of encounters remained the same (5 (2-1)) for those with access. Fewer patients received a blood pressure measurement (47.9% to 31.8%), and patients received fewer measurements during the pandemic (2 (1-4) to 1 (0-2)).

CONCLUSIONS

Encounters with primary care remained consistent during the pandemic, but in-person care, such as lab tests and blood pressure measurements, decreased. In-person care indicators followed temporally to national COVID-19 case counts during the pandemic.

Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system

BACKGROUND

Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system.

METHODS

We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016.

RESULTS

The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses.

CONCLUSIONS

The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

Access of older people to primary health care in low and middle-income countries: A systematic scoping review

INTRODUCTION

Ensuring access for older people to Primary Health Care (PHC) is vital to achieve universal health coverage, improve health outcomes, and health-system performance. However, older people living in Low-and Middle-Income Countries (LMICs) face barriers constraining their timely access to appropriate care. This review aims to summarize the nature and breadth of literature examining older people's experiences with access to PHC in LMICs, and access barriers and enablers.

METHODS

Guided by Arksey and O'Malley's framework, four databases [CINAHL, Cochrane, PubMed, and Embase] were systematically searched for all types of peer-reviewed articles published between 2002 and 2023, in any language but with English or French abstract. Gray literature presenting empirical data was also included by searching the United Nations, World Health Organization, and HelpAge websites. Data were independently screened and extracted.

RESULTS

Of 1165 identified records, 30 are included. Data were generated mostly in Brazil (50%) and through studies adopting quantitative designs (80%). Older people's experiences varied across countries and were shaped by several access barriers and enablers classified according to the Patient-Centered Access to Healthcare framework, featuring the characteristics of the care delivery system at the supply side and older people's attributes from the demand side. The review identifies that most access barriers and enablers pertain to the availability and accommodation dimension, followed by the appropriateness, affordability, acceptability, and approachability of services. Socio-economic level and need perception were the most reported characteristics that affected older people's access to PHC.

CONCLUSIONS

Older people's experiences with PHC access varied according to local contexts, socioeconomic variables, and the provision of public or private health services. Results inform policymakers and PHC practitioners to generate policies and services that are evidence-based and responsive to older people's needs. Identified knowledge gaps highlight the need for research to further understand older people's access to PHC in different LMICs.

Teamwork and its impact on chronic disease clinical outcomes in primary care: a systematic review and meta-analysis

OBJECTIVE

Teamwork positively affects staff performance and patient outcomes in chronic disease management. However, there is limited research on the impact of specific team components on clinical outcomes. This review aims to explore the impact of teamwork components on key clinical outcomes of chronic diseases in primary care.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis conducted searching EMBASE, PubMed, Cochrane Central Register of Controlled Trials. Studies included must have at least one teamwork component, conducted in primary care for selected chronic diseases, and report an impact of teamwork on clinical outcomes. Mean differences and 95% confidence intervals were used to determine pooled effects of intervention.

RESULTS

A total of 54 studies from 1988 to 2021 were reviewed. Shared decision-making, roles sharing, and leadership were missing in most studies. Team-based intervention showed a reduction in mean systolic blood pressure (MD = 5.88, 95% CI 3.29-8.46, P= <0.001, I2 = 95%), diastolic blood pressure (MD = 3.23, 95% CI 1.53 to 4.92, P = <0.001, I2 = 94%), and HbA1C (MD = 0.38, 95% CI 0.21 to 0.54, P = <0.001, I2 = 58%). More team components led to better SBP and DBP outcomes, while individual team components have no impact on HbA1C. Fewer studies limit analysis of cholesterol levels, hospitalizations, emergency visits and chronic obstructive pulmonary disease-related outcomes.

CONCLUSION

Team-based interventions improve outcomes for chronic diseases, but more research is needed on managing cholesterol, hospitalizations, and chronic obstructive pulmonary disease. Studies with 4-5 team components were more effective in reducing systolic blood pressure and diastolic blood pressure. Heterogeneity should be considered, and additional research is needed to optimize interventions for specific patient populations.

Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol

BACKGROUND

The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been widely used in practice and research to evaluate health service quality and efficiency worldwide. The definition of ACSCs varies across countries due to different challenges posed on healthcare systems. However, China does not have its own list of ACSCs. The study aims to develop a list to meet health system monitoring, reporting and evaluation needs in China.

METHODS

To develop the list, we will combine the best methodological evidence available with real-world evidence, adopt a systematic and rigorous process and absorb multidisciplinary expertise. Specific steps include: (1) establishment of working groups; (2) generations of the initial list (review of already published lists, semi-structured interviews, calculations of hospitalization rate); (3) optimization of the list (evidence evaluation, Delphi consensus survey); and (4) approval of a final version of China's ACSCs list. Within each step of the process, we will calculate frequencies and proportions, use descriptive analysis to summarize and draw conclusions, discuss the results, draft a report, and refine the list.

DISCUSSION

Once completed, China's list of ACSCs can be used to comprehensively evaluate the current situation and performance of health services, identify flaws and deficiencies embedded in the healthcare system to provide evidence-based implications to inform decision-makings towards the optimization of China's healthcare system. The experiences might be broadly applicable and serve the purpose of being a prime example for nations with similar conditions.

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: A scoping review

AIMS

To explore and summarise the literature on the concept of 'clinical deterioration' as a nurse-sensitive indicator of quality of care in the out-of-hospital context.

DESIGN

The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review and the JBI best practice guidelines for scoping reviews.

METHODS

Studies focusing on clinical deterioration, errors of omission, nurse sensitive indicators and the quality of nursing and midwifery care for all categories of registered, enrolled, or licensed practice nurses and midwives in the out-of-hospital context were included regardless of methodology. Text and opinion papers were also considered. Study protocols were excluded.

DATA SOURCES

Data bases were searched from inception to June 2022 and included CINAHL, PsychINFO, MEDLINE, The Allied and Complementary Medicine Database, EmCare, Maternity and Infant Care Database, Australian Indigenous HealthInfoNet, Informit Health and Society Database, JSTOR, Nursing and Allied Health Database, RURAL, Cochrane Library and Joanna Briggs Institute.

RESULTS

Thirty-four studies were included. Workloads, education and training opportunities, access to technology, home visits, clinical assessments and use of screening tools or guidelines impacted the ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting.

CONCLUSIONS

Little is known about the work of nurses or midwives in out-of-hospital settings and their recognition, reaction to and relay of information about patient deterioration. The complex and subtle nature of non-acute deterioration creates challenges in defining and subsequently evaluating the role and impact of nurses in these settings.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Further research is needed to clarify outcome measures and nurse contribution to the care of the deteriorating patient in the out-of-hospital setting to reduce the rate of avoidable hospitalisation and articulate the contribution of nurses and midwives to patient care.

IMPACT

What Problem Did the Study Address? Factors that impact a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting are not examined to date. What Were the Main Findings? A range of factors were identified that impacted a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting including workloads, education and training opportunities, access to technology, home visits, clinical assessments, use of screening tools or guidelines, and avoidable hospitalisation. Where and on whom will the research have an impact? Nurses and nursing management will benefit from understanding the factors that act as barriers and facilitators for effective recognition of, and responding to, a deteriorating patient in the out-of-hospital setting. This in turn will impact patient survival and satisfaction.

REPORTING METHOD

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines guided this review. The PRISMA-Scr Checklist (Tricco et al., 2018) is included as (supplementary file 1).Data sharing is not applicable to this article as no new data were created or analysed in this study."

NO PATIENT OR PUBLIC CONTRIBUTION

Not required as the Scoping Review used publicly available information.

Change in avoidable hospitalizations for low-income elders following quasi-market reform in primary care - Evidence from a natural experiment in Sweden

Quasi-market reforms have been increasingly implemented in tax-funded health care, but their effects in terms of equity, quality and socioeconomic differentials in quality remain sparsely studied. We create a natural experiment setup exploiting the differential timing of a set of quasi-market reforms - including patient choice, free establishment of providers and changes in provider remuneration -, implemented in primary care in the two largest Swedish regions (Stockholm and Västra Götaland) in 2008-2009. Using a database with individual level data from 2005 to 2009, we construct a difference-in-difference-in-differences model that compares pre to post reform changes in avoidable hospitalizations (AHs) for low-income elders and a matched comparison group, in the region exposed to, versus unexposed to, reform (total N ∼ 200 000). The results show that for low-income elders - a group dominated by older women - reform led to higher AH rates, i.e., worse primary health care quality, than what would have been the case in absence of reform. Specifically, low-income elders exposed to reform missed out on improvements in AHs seen simultaneously in the unexposed region. At the same time, the reform had on average no effect for comparable, non-low-income, peers. The fact that this pattern was specific for avoidable hospitalizations - judged as amenable to interventions in primary care -, but not present for total hospitalizations, supports that it was driven by reform implementation rather than other factors. The study contributes with high-quality empirical evidence to a policy relevant but sparsely researched area and highlights the necessity to consider differential effects of organizational changes across socioeconomic groups.

Enhancing Health Care Accessibility and Equity Through a Geoprocessing Toolbox for Spatial Accessibility Analysis: Development and Case Study

BACKGROUND

Access to health care services is a critical determinant of population health and well-being. Measuring spatial accessibility to health services is essential for understanding health care distribution and addressing potential inequities.

OBJECTIVE

In this study, we developed a geoprocessing toolbox including Python script tools for the ArcGIS Pro environment to measure the spatial accessibility of health services using both classic and enhanced versions of the 2-step floating catchment area method.

METHODS

Each of our tools incorporated both distance buffers and travel time catchments to calculate accessibility scores based on users' choices. Additionally, we developed a separate tool to create travel time catchments that is compatible with both locally available network data sets and ArcGIS Online data sources. We conducted a case study focusing on the accessibility of hemodialysis services in the state of Tennessee using the 4 versions of the accessibility tools. Notably, the calculation of the target population considered age as a significant nonspatial factor influencing hemodialysis service accessibility. Weighted populations were calculated using end-stage renal disease incidence rates in different age groups.

RESULTS

The implemented tools are made accessible through ArcGIS Online for free use by the research community. The case study revealed disparities in the accessibility of hemodialysis services, with urban areas demonstrating higher scores compared to rural and suburban regions.

CONCLUSIONS

These geoprocessing tools can serve as valuable decision-support resources for health care providers, organizations, and policy makers to improve equitable access to health care services. This comprehensive approach to measuring spatial accessibility can empower health care stakeholders to address health care distribution challenges effectively.

A novel application of interrupted time series analysis to identify the impact of a primary health care reform on intersectional inequities in avoidable hospitalizations in the adult Swedish population

Primary health care (PHC) systems are a crucial instrument for achieving equitable population health, but there is little evidence of how PHC reforms impact equities in population health. In 2010, Sweden implemented a reform that promoted marketization and privatization of PHC. The present study uses a novel integration of intersectionality-informed and evaluative epidemiological analytical frameworks to disentangle the impact of the 2010 Swedish PHC reform on intersectional inequities in avoidable hospitalizations. The study population comprised the total Swedish population aged 18-85 years across 2001-2017, in total 129 million annual observations, for whom register data on sociodemographics and hospitalizations due to ambulatory care sensitive conditions were retrieved. Multilevel Analysis of Individual Heterogeneity and Discriminatory Analyses (MAIHDA) were run for the pre-reform (2001-2009) and post-reform (2010-2017) periods to provide a mapping of inequities. In addition, random effects estimates reflecting the discriminatory accuracy of intersectional strata were extracted from a series MAIHDAs run per year 2001-2017. The estimates were re-analyzed by Interrupted Time Series Analysis (ITSA), in order to identify the impact of the reform on measures of intersectional inequity in avoidable hospitalizations. The results point to a complex reconfiguration of social inequities following the reform. While the post-reform period showed a reduction in overall rates of avoidable hospitalizations and in age disparities, socioeconomic inequities in avoidable hospitalizations, as well as the importance of interactions between complex social positions, both increased. Socioeconomically disadvantaged groups born in the Nordic countries seem to have benefited the least from the reform. The study supports a greater attention to the potentially complex consequences that health reforms can have on inequities in health and health care, which may not be immediate apparent in conventional evaluations of either population-average outcomes, or by simple evaluations of equity impacts. Methodological approaches for evaluation of complex inequity impacts need further development.

Optimizing the medical equipment investment in primary care centres in rural China: evidence from a panel threshold model

BACKGROUND

The previous "one-size-fits-all" practice in resource allocation can no longer adapt to the spatial variation in population and health needs. This study aimed to investigate the spatially heterogeneous effect of medical equipment investment in the township health centres in rural China to optimize the investment strategies.

METHODS

Based on the national-scale stratified multistage cluster sampling, 319 township health centres from six provinces were included in the study. The retrospective data from 2013 to 2017 were collected for each sampled township health centres and the corresponding township community. The panel threshold regression model was applied to estimate the nonlinear effect of medical equipment increment on the service utilization due to the township communities' urbanization degree. The influence of township community remoteness on the effects of equipment increment was investigated through subgroup analysis.

RESULTS

Among the township health centres in the neighbouring towns of the county seat (travel time to the county seat < 1 h), the significant effect of medical equipment increment was only found in the township health centres of the towns with high urbanization degrees (the proportion of the residents living in the built-up area > 69.89%), of which the effect size was 774.81 (95% CI 495.63, 1053.98, p < 0.05). Among the township health centres in the remote towns (travel time ≥ 1 h), the effect of medical equipment increment in the township health centres of the low urbanized towns (urban ≤ 5.99%, β = 1052.54, p < 0.01) was around four times the size of that of the counterparts (urban > 5.99%, β = 237.00, p < 0.01).

CONCLUSION

This study demonstrated the spatially heterogeneous effect of medical equipment investment in the primary care centres in rural China. The priority of the equipment investment was suggested to be given to the township health centres in the remote towns with a low urbanization degree and those in the highly-urbanized neighbouring towns of the county seats.

Nurse Practitioner Care Environments and Racial and Ethnic Disparities in Hospitalization Among Medicare Beneficiaries with Coronary Heart Disease

BACKGROUND

Nurse practitioners care for patients with cardiovascular disease, particularly those from racial and ethnic minority groups, and can help assure equitable health outcomes. Yet, nurse practitioners practice in challenging care environments, which limits their ability to care for patients.

OBJECTIVE

To determine whether primary care nurse practitioner care environments are associated with racial and ethnic disparities in hospitalizations among older adults with coronary heart disease.

DESIGN

In this observational study, a cross-sectional survey was conducted among primary care nurse practitioners in 2018-2019 who completed a valid measure of care environment. The data was merged with 2018 Medicare claims data for patients with coronary heart disease.

PARTICIPANTS

A total of 1244 primary care nurse practitioners and 180,216 Medicare beneficiaries 65 and older with coronary heart disease were included.

MAIN MEASURES

All-cause and ambulatory care sensitive condition hospitalizations in 2018.

KEY RESULTS

There were 50,233 hospitalizations, 9068 for ambulatory care sensitive conditions. About 28% of patients had at least one hospitalization. Hospitalizations varied by race, being highest among Black patients (33.5%). Care environment moderated the relationship between race (Black versus White) and hospitalization (OR 0.93; 95% CI, 0.88-0.98). The lowest care environment was associated with greater hospitalization among Black (odds ratio=1.34; 95% CI, 1.20-1.49) compared to White beneficiaries. Practices with the highest care environment had no racial differences in hospitalizations. There was no interaction effect between care environment and race for ambulatory care sensitive condition hospitalizations. Nurse practitioner care environment had a protective effect on these hospitalizations (OR, 0.96; 95% CI, 0.92-0.99) for all beneficiaries.

CONCLUSIONS

Unfavorable care environments were associated with higher hospitalization rates among Black than among White beneficiaries with coronary heart disease. Racial disparities in hospitalization rates were not detected in practices with high-quality care environments, suggesting that improving nurse practitioner care environments could reduce racial disparities in hospitalizations.

Gravity models for potential spatial healthcare access measurement: a systematic methodological review

BACKGROUND

Quantifying spatial access to care-the interplay of accessibility and availability-is vital for healthcare planning and understanding implications of services (mal-)distribution. A plethora of methods aims to measure potential spatial access to healthcare services. The current study conducts a systematic review to identify and assess gravity model-type methods for spatial healthcare access measurement and to summarize the use of these measures in empirical research.

METHODS

A two-step approach was used to identify (1) methodological studies that presented a novel gravity model for measuring spatial access to healthcare and (2) empirical studies that applied one of these methods in a healthcare context. The review was conducted according to the PRISMA guidelines. EMBASE, CINAHL, Web of Science, and Scopus were searched in the first step. Forward citation search was used in the second step.

RESULTS

We identified 43 studies presenting a methodological development and 346 empirical application cases of those methods in 309 studies. Two major conceptual developments emerged: The Two-Step Floating Catchment Area (2SFCA) method and the Kernel Density (KD) method. Virtually all other methodological developments evolved from the 2SFCA method, forming the 2SFCA method family. Novel methodologies within the 2SFCA family introduced developments regarding distance decay within the catchment area, variable catchment area sizes, outcome unit, provider competition, local and global distance decay, subgroup-specific access, multiple transportation modes, and time-dependent access. Methodological developments aimed to either approximate reality, fit a specific context, or correct methodology. Empirical studies almost exclusively applied methods from the 2SFCA family while other gravity model types were applied rarely. Distance decay within catchment areas was frequently implemented in application studies, however, the initial 2SFCA method remains common in empirical research. Most empirical studies used the spatial access measure for descriptive purposes. Increasingly, gravity model measures also served as potential explanatory factor for health outcomes.

CONCLUSIONS

Gravity models for measuring potential spatial healthcare access are almost exclusively dominated by the family of 2SFCA methods-both for methodological developments and applications in empirical research. While methodological developments incorporate increasing methodological complexity, research practice largely applies gravity models with straightforward intuition and moderate data and computational requirements.

Association between hospitalizations for sensitive conditions and quality of primary care

OBJECTIVE

To analyze the association between municipal rates of ambulatory care sensitive conditions (ACSC) hospitalization and the quality of primary health care (PHC), socioeconomic, and demographic variables and those related to local characteristics of the health system from 2010 to 2019.

METHOD

Ecological time series study in Brazilian municipalities analyzing the correlation of ACSC hospitalization rates with PHC quality measured by the three cycles of the Primary Care Access and Program for improving primary care access and quality (PMAQ-AB). The study included municipalities whose teams participated in 80% or more of at least two PMAQ-AB cycles. The correlation between standardized ACSC hospitalization rates and PHC quality and other variables was analyzed. Spearman's test was used between the response variable and numerical explanatory variables. Generalized equations estimation was used as a multivariate model associating ACSC hospitalization rates with the other variables over the years.

RESULTS

A total of 3,500 municipalities were included in the models. The quality of PHC (PMAQ-AB score) showed an inverse association with the variation in ACSC hospitalization rates. Hospitalization rates fell by -2% per year every ten-point increase in the PMAQ-AB score, adjusted by the remaining variables. A one-unit increase in the beds per 1,000 inhabitants variable had an impact of approximately +6.4% on ACSC hospitalization rates. Regarding population size, larger municipalities had lower ACSC hospitalization rates. Increased PHC coverage and lower socioeconomic inequality were also associated with the reduction in hospitalizations.

CONCLUSIONS

The reduction in ACSC hospitalization rates over time was associated with an increase in the quality of PHC. It was also associated with a reduction in the number of hospital beds and municipalities with better socioeconomic indicators.

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

BACKGROUND

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.

OBJECTIVE

To describe national hospitalization rates due to ACSCs among adult inpatients in the US.

DESIGN

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

Participants were adult inpatients from community hospitals in 48 states of the US and District of Columbia.

MAIN MEASURES

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.

KEY RESULTS

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.

CONCLUSIONS

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.

Transformation to a patient-centred medical home led and delivered by an urban Aboriginal and Torres Strait Islander community, and association with engagement and quality-of-care: quantitative findings from a pilot study

BACKGROUND

The patient-centred medical home (PCMH) is a model of team-based primary care that is patient-centred, coordinated, accessible, and focused on quality and safety. In response to substantial population growth and increasing demand on existing primary care services, the Institute for Urban Indigenous Health (IUIH) developed the IUIH System of Care-2 (ISoC2), based on an international Indigenous-led PCMH. ISoC2 was piloted at an urban Aboriginal and Torres Strait Islander Community-Controlled Health Service in South-East Queensland between 2019-2020, with further adaptations made to ensure its cultural and clinical relevance to local Aboriginal and Torres Strait Islander people. Little is known on the implementation and impact of PCMH in the Australian Indigenous primary care setting. Changes in implementation process measures and outcomes relating to engagement and quality-of-care are described here.

METHODS

De-identified routinely collected data extracted from electronic health records for clients regularly attending the service were examined to assess pre-post implementation changes relevant to the study. Process measures included enrolment in PCMH team-based care, and outcome measures included engagement with the health service, continuity-of-care and clinical outcomes.

RESULTS

The number of regular clients within the health service increased from 1,186 pre implementation to 1,606 post implementation; representing a small decrease as a proportion of the services' catchment population (38.5 to 37.6%). In clients assigned to a care team (60% by end 2020), care was more evenly distributed between providers, with an increased proportion of services provided by the Aboriginal and Torres Strait Islander Health Worker (16-17% versus 10-11%). Post-implementation, 41% of clients had continuity-of-care with their assigned care team, while total, preventive and chronic disease services were comparable pre- and post-implementation. Screening for absolute cardiovascular disease risk improved, although there were no changes in clinical outcomes.

CONCLUSIONS

The increase in the number of regular clients assigned to a team and their even distribution of care among care team members provides empirical evidence that the service is transforming to a PCMH. Despite a complex transformation process compounded by the COVID-19 pandemic, levels of service delivery and quality remained relatively stable, with some improvements in risk factor screening.

Emergency department utilization, admissions, and revisits in the United States (New York), Canada (Ontario), and New Zealand: A retrospective cross-sectional analysis

BACKGROUND

Emergency department (ED) utilization is a significant concern in many countries, but few population-based studies have compared ED use. Our objective was to compare ED utilization in New York (United States), Ontario (Canada), and New Zealand (NZ).

METHODS

A retrospective cross-sectional analysis of all ED visits between January 1, 2016, and September 30, 2017, for adults ≥18 years using data from the State Emergency Department and Inpatient Databases (New York), the National Ambulatory Care Reporting System and Discharge Abstract Data (Ontario), and the National Non-Admitted Patient Collection and the National Minimum Data Set (New Zealand). Outcomes included age- and sex-standardized per-capita ED utilization (overall and stratified by neighborhood income), ED disposition, and ED revisit and hospitalization within 30 days of ED discharge.

RESULTS

There were 10,998,371 ED visits in New York, 8,754,751 in Ontario, and 1,547,801 in New Zealand. Patients were older in Ontario (mean age 51.1 years) compared to New Zealand (50.3) and New York (48.7). Annual sex- and age-standardized per-capita ED utilization was higher in Ontario than New York or New Zealand (443.2 vs. 404.0 or 248.4 visits per 1000 population/year, respectively). In all countries, ED utilization was highest for residents of the lowest income quintile neighborhoods. The proportion of ED visits resulting in hospitalization was higher in New Zealand (34.5%) compared to New York (20.8%) and Ontario (12.8%). Thirty-day ED revisits were higher in Ontario (27.0%) than New Zealand (18.6%) or New York (21.4%).

CONCLUSIONS

Patterns of ED utilization differed widely across three high-income countries. These differences highlight the varying approaches that our countries take with respect to urgent visits, suggest opportunities for shared learning through international comparisons, and raise important questions about optimal approaches for all countries.

Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis

BACKGROUND

Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care.

METHODS

Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models.

RESULTS

Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16).

INTERPRETATION

Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.

Determinants of province-based health service utilization according to Andersen' s Behavioral Model: a population-based spatial panel modeling study

OBJECTIVE

The Andersen' s Behavioral Model was used to explore the impact of various factors on the utilization of health services. The purpose of this study is to establish a provincial-level proxy framework for the utilization of health services from a spatial perspective, based on the influencing factors of the Andersen' s Behavioral Model.

METHOD

Provincial-level health service utilization was estimated by the annual hospitalization rate of residents and the average number of outpatient visits per year from China Statistical Yearbook 2010-2021. Exploring the relevant influencing factors of health service utilization using the spatial panel Durbin model. Spatial spillover effects were introduced to interpret the direct and indirect effects influenced by the proxy framework for predisposing, enabling, and need factors on health services utilization.

RESULTS

From 2010 - 2020, the resident hospitalization rate increased from 6.39% ± 1.23% to 15.57% ± 2.61%, and the average number of outpatient visits per year increased from 1.53 ± 0.86 to 5.30 ± 1.54 in China. For different provinces, the utilization of health services is uneven. The results of the Durbin model show that locally influencing factors were statistically significantly related to an increase in the resident hospitalization rate, including the proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index, while statistically related to the average number of outpatient visits per year, including the illiteracy rate and GDP per capita. Direct and indirect effects decomposition of resident hospitalization rate associated influencing factors demonstrated that proportion of 65-year-olds, GDP per capita, percentage of medical insurance participants, and health resources index not only affected local resident hospitalization rate but also exerted spatial spillover effects toward geographical neighbors. The illiteracy rate and GDP per capita have significant local and neighbor impacts on the average number of outpatient visits.

CONCLUSION

Health services utilization was a variable varied by region and should be considered in a geographic context with spatial attributes. From the spatial perspective, this study identified the local and neighbor impacts of predisposing factors, enabling factors, and need factors that contributed to disparities in local health services utilization.

Potentially Avoidable Hospitalizations by Asthma and COPD in Switzerland from 1998 to 2018: A Cross-Sectional Study

Potentially avoidable hospitalizations (PAH) are commonly used as an indicator for healthcare quality and primary care performance. However, data are usually presented in a restricted timeframe and for a specific region, limiting the identification of trends and national patterns. We aimed in this study to calculate rates, identify clinical determinants, and estimate costs of PAH for two frequent lung diseases (asthma and COPD) in Switzerland between 1998 and 2018 using hospital discharge data available for patients aged ≥20 years. PAH were defined according to the Health Care Quality Indicators Project (HCQIP) from the Organisation for Economic Co-operation and Development (OECD). The distribution of PAH in seven administrative regions (Leman, Mittelland, Northwest, Zurich, Eastern, Central, and Ticino) was calculated, along with PAH-associated total hospital days and Diagnosis-Related Group (DRG) estimated costs. Totals of 25,260 PAH for asthma and 135,069 PAH for COPD were identified in the 20-year period. The standardized rates of PAH per 100,000 people for asthma fluctuated from 18.7 in 1998 to 22.5 on 2018. The standardized rates of PAH per 100,000 people from COPD almost doubled from 77.4 in 1998 to 142.7 in 2018. In 2018, the estimated total costs of PAH amounted to 7.7 million CHF for asthma and 91.2 million CHF for COPD. We conclude that PAH for asthma and COPD represent a significant and unnecessary burden and costs of hospitalizations in Switzerland.

Socioeconomic differences in older adults' unplanned hospital admissions: the role of health status and social network

BACKGROUND

the socioeconomic distribution of unplanned hospital admissions in older adults is poorly understood. We compared associations of two life-course measures of socioeconomic status (SES) with unplanned hospital admissions while comprehensively accounting for health, and examined the role of social network in this association.

METHODS

in 2,862 community-dwelling adults aged 60+ in Sweden, we derived (i) an aggregate life-course SES measure grouping individuals into Low, Middle or High SES based on a summative score, and (ii) a latent class measure that additionally identified a Mixed SES group, characterised by financial difficulties in childhood and old age. The health assessment combined measures of morbidity and functioning. The social network measure included social connections and support components. Negative binomial models estimated the change in hospital admissions over 4 years in relation to SES. Stratification and statistical interaction assessed effect modification by social network.

RESULTS

adjusting for health and social network, unplanned hospitalisation rates were higher for the latent Low SES and Mixed SES group (incidence rate ratio [IRR] = 1.38, 95% confidence interval [CI]: 1.12-1.69, P = 0.002; IRR = 2.06, 95% CI: 1.44-2.94, P < 0.001; respectively; ref: High SES). Mixed SES was at a substantially greater risk of unplanned hospital admissions among those with poor (and not rich) social network (IRR: 2.43, 95% CI: 1.44-4.07; ref: High SES), but the statistical interaction test was non-significant (P = 0.493).

CONCLUSION

socioeconomic distributions of older adults' unplanned hospitalisations were largely driven by health, although considering SES dynamics across life can reveal at-risk sub-populations. Financially disadvantaged older adults might benefit from interventions aimed at improving their social network.

Association of Cost-Driven Residential Moves With Health-Related Outcomes Among California Renters

IMPORTANCE

Unaffordable housing is associated with adverse health-related outcomes, but little is known about the associations between moving due to unaffordable housing and health-related outcomes.

OBJECTIVE

To characterize the association of recent cost-driven residential moves with health-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study involved a weighted multivariable regression analysis of California Health Interview Survey data from January 1, 2011, to December 31, 2017. A population-based sample of 52 646 adult renters and other nonhomeowners in California were included. Data were analyzed from March 2, 2021, to January 6, 2023.

EXPOSURE

Cost-driven moves in the past 3 years relative to no move and to non-cost-driven moves.

MAIN OUTCOMES AND MEASURES

Five outcomes were assessed: psychological distress (low, moderate, or severe, as categorized by the 6-item Kessler Psychological Distress Scale), emergency department [ED] visits in the past year (any vs none), preventive care visits in the past year (any vs none), general health (poor or fair vs good, very good, or excellent), and walking for leisure in the past 7 days (in minutes).

RESULTS

Among 52 646 adult renters and other nonhomeowners, 50.3% were female, 85.2% were younger than 60 years, 45.3% were Hispanic, and 55.1% had income lower than 200% of the federal poverty level. Overall, 8.9% of renters reported making a recent cost-driven move, with higher prevalence among Hispanic (9.9%) and non-Hispanic Black (11.3%) renters compared with non-Hispanic White renters (7.2%). In multivariable models, compared with not moving, cost-driven moving was associated with a 4.2 (95% CI, 2.6-5.7) percentage point higher probability of experiencing moderate psychological distress; a 3.2 (95% CI, 1.9-4.5) percentage point higher probability of experiencing severe psychological distress; a 2.5 (95% CI, 0-4.9) percentage point higher probability of ED visits; a 5.1 (95% CI, 1.6-8.6) percentage point lower probability of having preventive care visits; a 3.7 (95% CI, 1.2-6.2) percentage point lower probability of having good, very good, or excellent general health; and 16.8 (95% CI, 6.9-26.6) fewer minutes of walking for leisure. General health, psychological distress, and walking for leisure were also worse with cost-driven moves relative to non-cost-driven moves, with a 3.2 (95% CI, 1.7-4.7) percentage point higher probability of experiencing moderate psychological distress; a 2.5 (95% CI, 1.2-3.9) percentage point higher probability of experiencing severe psychological distress; a 4.6 (95% CI, 2.1-7.2) percentage point lower probability of having good, very good, or excellent general health; and 13.0 (95% CI, 4.0-21.9) fewer minutes of walking for leisure. However, the incidence of preventive care and ED visits did not differ between those who made cost-driven vs non-cost-driven moves.

CONCLUSIONS AND RELEVANCE

In this study, cost-driven moves were associated with adverse health-related outcomes relative to not moving and to non-cost-driven moves. These findings suggest that policies to improve housing affordability, prevent displacement, and increase access to health care for groups vulnerable to cost-driven moves may have the potential to improve population health equity, especially during the current national housing affordability crisis.

Potentially preventable hospitalisations in rural community-dwelling patients

BACKGROUND

Potentially preventable hospitalisations (PPH) are a common occurrence. Knowing the factors associated with PPH may allow high-risk patients to be identified and healthcare resources to be better allocated, and these factors may differ between urban and rural locations.

AIM

To determine factors associated with PPH in an Australian rural population.

METHODS

A retrospective review of admitted patients' demographic and clinical data was used to describe and model the factors associated with PPH, using an age- and sex-matched control group of non-admitted patients. This study is based in a multi-site rural general practice, Tasmania. The study included patients aged ≥18 years residing in the Huon-Bruny Island region of Tasmania, who were active patients at a rural general practice and were admitted to a public hospital for a PPH between 1 July 2016 and 30 June 2019. Main outcome measure is overnight admission to hospital for a PPH.

RESULTS

Predictors with a significant odds ratio (OR) in the final model were being single/unmarried (OR 2.43; 95% confidence interval (CI) 1.38-4.28), higher Charlson Comorbidity Index score (OR 1.40; 95% CI 1.13-1.74) and the number of general practice visits in the preceding 12 months (OR 1.09; 95% CI 1.05-1.14).

CONCLUSIONS

This study found that being single and having a higher comorbidity burden were the strongest independent risk factors for PPH in a rural population. Demographic and socioeconomic factors appeared to be as, if not more, important than medical factors and warrant attention when considering the design of programmes to reduce PPH risk in rural communities.

Incipient dementia and avoidable hospital admission in persons with osteoarthritis

Objective

To investigate the associations between incipient dementia (ID) and hospitalization for ambulatory care sensitive conditions (ACSCs) among people with osteoarthritis (OA) of the peripheral joints.

Methods

Among 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.

Results

There 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.

Conclusions

Among 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.

Comparison of the risks of occupational diseases, avoidable hospitalization, and all-cause deaths between firefighters and non-firefighters: A cohort study using national health insurance claims data

Objectives

National Health Insurance claims data were used to compare the incidence of occupational diseases, avoidable hospitalization, and all-cause death standardized incidence ratio and hazard ratio between firefighters and non-firefighters.

Methods

The observation period of the study was from 2006 to 2015 and a control group (general workers and national and regional government officers/public educational officers) and a firefighter group was established. The dependent variables were occupational diseases, avoidable hospitalization (AH), and all-cause death. The analysis was conducted in three stages. First, the standardized incidence ratios were calculated using the indirect standardization method to compare the prevalence of the disease between the groups (firefighter and non-firefighter groups). Second, propensity score matching was performed for each disease in the control group. Third, the Cox proportional hazards model was applied by matching the participants.

Results

The standardized incidence ratio and Cox regression analyses revealed higher rates of noise-induced hearing loss, ischemic heart disease, asthma, chronic obstructive pulmonary disease, cancer, back pain, admission due to injury, mental illness, depression, and AH for firefighters than general workers. Similarly, the rates of noise-induced hearing loss, ischemic heart disease, asthma, chronic obstructive pulmonary disease, back pain, admission due to injury, mental illness, depression, and AH were higher in the firefighter group than in the national and regional government officer/public educational officer group.

Conclusions

The standardized incidence ratios and hazard ratios for most diseases were high for firefighters. Therefore, besides the prevention and management of diseases from a preventive medical perspective, management programs, including social support and social prescriptions in the health aspect, are needed.

The Impact of Primary Care Practice Models on Indicators of Unplanned Health Care Utilization for Ontario Adults Newly Diagnosed With Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic disease. Most of the care for this population occurs within the primary care setting; however, the extent to which different primary care practice models influence the outcomes of patients with COPD remains unclear.

OBJECTIVE

The study aimed to compare and analyze the influence of different primary care practice models on indicators of unplanned health care utilization among newly diagnosed COPD patients in Ontario.

DESIGN

A retrospective cohort study was conducted using health administrative database within the Institute for Clinical Evaluative Sciences. The cohort included persons who were 35 years and older with physician-diagnosed COPD between January 1, 2014 and December 31, 2019. Patients were assigned into 3 practice models: team-based, traditional, and no enrolment. The primary outcomes examined was unplanned health care utilization, specifically emergency department (ED) visits and hospitalizations. To account for excessive zero values, the zero inflated negative binomial (ZINB) models were used to analyze the association between different practice models and unplanned health care utilization.

RESULTS

Among 57,145 individuals who met the inclusion criteria, 55,994 were included in the regression analysis. Of the included participants, 62.8% of patients were in the traditional group, 30.3% were in the team-based group, and 6.9% were in the no enrolment group. Between 2014 and 2019, 70.7% of the cohort had at least 1 all-cause ED visit without hospitalization. The adjusted ZINB models showed no significant difference in risks of experiencing an unplanned health care utilization between the team-based and traditional groups. However, patients in the no enrolment group had a significantly higher risk of ED visit without hospitalization regardless of cause, ED visit with hospitalization regardless of cause, and 30-day readmissions regardless of cause.

CONCLUSIONS

Primary care practice models are complex, influenced by remuneration and organizational structures, reinforcing the need for further research to enhance our understanding of primary care reforms. Furthermore, given the growing shortage of primary care providers, patients with COPD and other chronic conditions are particularly vulnerable.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits

Background

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits.

Methods

We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category.

Results

There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults.

Conclusion

Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

Reductions in out-of-pocket prices and forward-looking moral hazard in health care demand

Little is known about how patients dynamically respond to a forthcoming reduction in health care out-of-pocket prices. Using a kinked Donut Regression Discontinuity design with kinks entering and exiting the donut, we evaluate a Swedish cost-sharing policy, where primary care out-of-pocket prices were eliminated at age 85. We find evidence of forward-looking moral hazard with older adults delaying primary care visits up to four months before the out-of-pocket elimination and shifting these visits until shortly after. These health care delays are driven by non-urgent care: non-physician visits, planned visits and follow up visits. We find no evidence of severe negative health effects in the short-term as a result of the delay. Contrary to our finding of forward-looking behavior with respect to out-of-pocket prices, we do not find evidence of typical moral hazard, as we do not find a persistent increase in primary health care use after the copayment elimination.

Factors associated with racial differences in all-cause 30-day readmission in adults with cardiovascular disease: an observational study of a large healthcare system

OBJECTIVE

To examine factors contributing to racial differences in 30-day readmission in patients with cardiovascular disease (CVD).

DESIGN

Patients were enrolled from 1 January 2015 to 31 August 2017 and data were collected from electronic health records and a standardised interview administered prior to discharge.

SETTING

Duke Heart Center in the Duke University Health System.

PARTICIPANTS

Patients aged 18 and older admitted for the treatment of cardiovascular-related conditions (n=734).

MAIN OUTCOME AND MEASURES

All-cause readmission within 30 days was the main outcome. Multivariate logistic regression models were used to examine whether and to what extent socioeconomic, psychosocial, behavioural and healthcare-related factors contributed to 30-day readmissions in Black and White CVD patients.

RESULTS

The median age of patients was 66 years and 18.1% (n=133) were readmitted within 30 days after discharge. Black patients were more likely than White patients to be readmitted (OR 1.62; 95% CI 1.18 to 2.23) and the racial difference in readmissions was largely reduced after taking into account differences in a wide range of clinical and non-clinical factors (OR 1.37; 95% CI 0.98 to 1.91). In Black patients, readmission risks were especially high in those who were retired (OR 3.71; 95% CI 1.71 to 8.07), never married (OR 2.21; 95% CI 1.21 to 4.05), had difficulty accessing their routine care (OR 2.88; 95% CI 1.70 to 4.88) or had been hospitalised in the prior year (OR 1.97; 95% CI 1.16 to 3.37). In White patients, being widowed (OR 2.39; 95% CI 1.41 to 4.07) and reporting a higher number of depressive symptoms (OR 1.07; 95% CI 1.00 to 1.13) were the key factors associated with higher risks of readmission.

CONCLUSIONS AND RELEVANCE

Black patients were more likely than White patients to be readmitted within 30 days after hospitalisation for CVD. The factors contributing to readmission differed by race and offer important clues for identifying patients at high risk of readmission and tailoring interventions to reduce these risks.

The impact of ambulatory care spending, continuity and processes of care on ambulatory care sensitive hospitalizations

Ambulatory care sensitive hospitalizations are widely considered as important measures of access to as well as quality and performance of primary care. In our study, we investigate the impact of spending, process quality and continuity of care in the ambulatory care sector on ambulatory care sensitive hospitalizations in patients with type 2 diabetes. We used observational data from Germany's major association of insurance companies from 2012 to 2014 with 55,924 patients, as well as data from additional sources. We conducted negative binomial regression analyses with random effects at the district level. To control for potential endogeneity of spending and physician density in the ambulatory care sector, we used an instrumental variable approach. We controlled for a wide range of covariates, such as age, sex, and comorbidities. The results of our analysis suggest that spending in the ambulatory care sector has weak negative effects on ambulatory care sensitive hospitalizations. We also found that continuity of care was negatively associated with hospital admissions. Patients with type 2 diabetes are at increased risk of hospitalization resulting from ambulatory care sensitive conditions. Our study provides some evidence that increased spending and improved continuity of care while controlling for process quality in the ambulatory care sector may be effective ways to reduce the rate of potentially avoidable hospitalizations among patients with type 2 diabetes.

Association between Primary Care Utilization and Emergency Room or Hospital Inpatient Services Utilization among the Middle-Aged and Elderly in a Self-Referral System: Evidence from the China Health and Retirement Longitudinal Study 2011-2018

With rapid economic growth and aging, hospital inpatient and emergency services utilization has grown rapidly, and has emphasized an urgent requirement to adjust and optimize the structure of health service utilization. Studies have shown that primary care is an effective way to reduce inpatient and emergency room (ER) service utilization. This study aims to examine whether middle-aged and elderly individuals who selected primary care outpatient services in the last month had less ER and hospital inpatient service utilization than those who selected hospitals outpatient services via the self-referral system. Data were obtained from four waves of the nationally representative China Health and Retirement Longitudinal Study (CHARLS). We pooled respondents who had outpatient visits and were aged 45 years and above. We used logistic regressions to explore the association between types of outpatient and ER visits or hospitalization, and then used zero-truncated negative binomial regression to examine the impact of outpatient visit types on the number of hospitalizations and the length of hospitalization days. A trend test was used to explore the trend of outpatient visit types and the ER or hospital inpatient services utilization with the increase in outpatient visits. Among the 7544 respondents in CHARLS, those with primary care outpatient visits were less likely to have ER visits (adjusted OR = 0.141, 95% CI: 0.101-0.194), hospitalization (adjusted OR = 0.623, 95% CI: 0.546-0.711), and had fewer hospitalization days (adjusted IRR = 0.886, 95% CI: 0.81-0.969). The trend test showed that an increase in the number of total outpatient visits was associated with a lower hospitalizations (p = 0.006), but a higher odds of ER visits (p = 0.023). Our findings suggest that policy makers need to adopt systematic policies that focus on restructuring and balancing the structure of resources and service utilization in the three-tier healthcare system.

Why Do Community-Dwelling Persons with Spinal Cord Injury Visit General Practitioners: A Cross-Sectional Study of Reasons for Encounter in Swiss General Practice

Purpose

In a country of free selection of providers, general practitioners (GPs) remain the most visited health-care professionals by the vast majority of persons with spinal cord injury (SCI) in Switzerland; yet, little is known about these contacts. The study aims to explore reasons for encounters (RFEs) in general practice, and their relationships to first-contact of care (GP or specialist) and GP’s competence in managing SCI-specific problems.

Patients and Methods

Cross-sectional study from baseline data of non-randomized controlled trial. Persons with SCI in the chronic phase and living in Swiss rural communities were invited. Participants were asked about RFEs (reasons and health problems) of their last visit to a GP. RFEs were coded according to the International Classification of Primary Care (ICPC-2), and analyzed according to first-contact and participants’ ratings of GPs’ competence in managing SCI-specific problems.

Results

Out of 395, 226 (57%) persons participated, of which 89% have reported 2.1 (SD ±1.4) RFEs and 2.4 (±1.7) health problems per GP visit, on average. Participants visited GPs for medications (49%), urgent medical problems (33%) and follow-up (30%). Most RFEs were related to general/unspecified problems (65%). Persons whose first contact was a specialist were more likely to visit GPs for medications (Specialist = 60% vs GP = 42%). There were no associations between RFEs and the perceived GP’s competence at P < 0.05.

Conclusion

Irrespective of first contact of care, persons with SCI visit GPs for medication, urgent issues, and follow-up care, and more often for general problems than for secondary health conditions. Strengthening collaboration between GPs in rural communities and specialized centers is recommended; promoting such a connection potentially aids GPs in meeting their information needs for managing secondary health conditions and improving the quality of SCI care for this population.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis

Background

Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).

Methods

A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups.

Results

Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.

Interpretation

Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs.

Funding

DFID/MRC/Wellcome Trust/ESRC.

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

Background

Individuals 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.

Methods

In 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.

Results

Each 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.

Conclusions

Increased 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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08326-2.

Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018

Objective

This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China.

Methods

In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations.

Results

From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased.

Conclusions

Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08275-w.

Osteoporosis Care Gap After Hip Fracture - Worse With Low Healthcare Access and Quality

Despite the burden of osteoporosis-related fractures and availability of effective treatment, a substantial osteoporosis care gap persists. We evaluated this gap following fragility hip fracture, testing the hypothesis that patients who live in areas with low health care access or quality are less likely to undergo evaluation or treatment following hip fragility fracture. This retrospective analysis quantified osteoporosis evaluation and treatment just prior and for 12 mo following fragility hip fracture at an academic medical center in the upper Midwest. Initiation of pharmacologic therapy, Vitamin D screening and dual energy X-ray absorptiometry (DXA) scanning were measured. Each patient was assigned a value for 3 metrics of regional healthcare access and quality: (1) population per PCP ratio, (2) percent un-insured <65 yrs old, and (3) preventable hospitalization >65 yrs old. Generalized estimating equations, with county as a random effect, were used to assess the association of patient characteristics and/or heath care metrics with osteoporosis treatment at the time of admission and/or osteoporosis evaluation and treatment during hospitalization and post-discharge. A total of 585 patients were 80.7 ± 8.4 yrs of age at the time of hip fragility fracture; 68% were women. In 12 mo post-fracture, 17% underwent vitamin D screening, 12% received a DXA scan and 17% began a new bone anti-resorptive medication. Only in-hospital Vitamin D screening was more common in patients from counties with low healthcare access; all other pre- and post-fracture care was more common for patients with greater healthcare access and quality. Overall rates of initiating pharmacologic treatment and/or obtaining a Vitamin D screen or DXA scan following hip fragility fracture were very low and were worse in patients from counties with low access and quality of healthcare. These results remind the practitioner to diagnose and treat osteoporosis following hip fracture and suggests a role for targeting high-risk groups.

Number of health care teams and hospitalizations due to primary care sensitive conditions

This study aimed to analyze the correlation between the number of health care teams of the Family Health Strategy (FHS) and the number of hospitalizations due to primary care sensitive conditions (HPCSC) taking into account rates, costs and hospital days in a large municipality of the state of Minas Gerais, Brazil, between 2010 and 2019. We performed an ecological time series correlation study on HPCSC of patients hospitalized by the public health system. Data were obtained from the Hospital Information System of the IT Department of the Public Health System (DATASUS) and from the Primary Care Information and Management System. The correlation analysis was performed based on the number, gross and standardized rates, percentages, costs and hospital days of HPCSC and health care coverage (average number of teams) using Spearman's correlation coefficient at a significance level of 5% (p < 0.05). No satisfactory correlation was found in the entire period between the increase in the number of health care teams and HPCSC (except for the standardized hospitalization rate). However, during the period in which the FHS coverage of the population was greater than 70%, all correlations were inversely proportional and statistically significant.

Diabetes-related avoidable hospitalisations and its relationship with primary healthcare resourcing in China: A cross-sectional study from Sichuan Province

The reduction of diabetes-related avoidable hospitalisations (AHs) can be achieved via the provision of timely and effective primary healthcare (PHC), which has made diabetes AHs rate a widely adopted indicator for evaluating the performances of PHC systems. This study reported the AHs rate of diabetes and further explored its relationship with PHC resourcing in China. Hospital discharge data of the fourth quarters of 2016 and 2017 in Sichuan Province, China were used. The number of PHC doctors per 10,000 population and the proportion of PHC doctors on all doctors were used as indicators reflective of PHC resourcing. Linear regression models were used to explore the associations between PHC resourcing and AHs of diabetes. Age-standardised rates of diabetes-related AHs in Sichuan province, China were found to be 248.102 and 272.368 per 100,000 population in 2016 and 2017, respectively. A 10% increase in the number of PHC doctors per 10,000 population was associated with a reduction of 2.574 per 100,000 population in the age-standardised AHs rate of diabetes. In addition, 10% increase in the proportion of PHC doctors on all doctors was associated with a reduction of 10.839 diabetes-related AHs per 100,000 population. Based on subgroup analysis, PHC resourcing demonstrated to have a stronger impact on AHs of diabetes with long-term complications than on that of uncontrolled diabetes. Our findings reported that the diabetes AHs rates in Sichuan Province were prevalently high. We also found that increased PHC resourcing was associated with decreased diabetes-related AHs rates.

Is Avoidable Hospitalization Experienced Prior to Infection Associated With COVID-19-Related Deaths?

Objectives: This study aimed to determine the effect of the presence or absence of avoidable hospitalization before acquiring coronavirus disease (COVID-19) on COVID-19-related deaths.

Methods: This study used the total NHIS-COVID-19 dataset comprising domestic COVID-19 patients, provided by the National Health Insurance Service (NHIS) in South Korea. We conducted logistic regression and double robust estimation (DRE) to confirm the effect of avoidable hospitalization on COVID-19-related deaths.

Results: Logistic regression analysis confirmed that the odds ratio (OR) of death due to COVID-19 was high in the group that experienced avoidable hospitalization. DRE analysis showed a higher OR of death due to COVID-19 in the group that experienced avoidable hospitalization compared to the group that did not experience avoidable hospitalization, except in the subgroup aged ≤69 years.

Conclusion: The effect of avoidable hospitalization on COVID-19-related deaths was confirmed. Therefore, continued health care, preventive medicine, and public health management are essential for reducing avoidable hospitalizations despite the COVID-19 pandemic. Clinicians need to be informed about the importance of continuous disease management.

Identifying patterns of potentially preventable hospitalisations in people living with dementia

BACKGROUND

Older Australians make up 46% of all potentially preventable hospitalisations (PPHs) and people living with dementia are at significantly greater risk. While policy reforms aim to reduce PPHs, there is currently little evidence available on what drives this, especially for people living with dementia. This study examines patterns of PPHs in people living with dementia to inform service delivery and the development of evidence-based interventions.

METHODS

We used the Victorian Admitted Episodes Dataset from Victoria, Australia, to extract data for people aged 50 and over with a diagnosis of dementia between 2015 and 2016. Potentially avoidable admissions, known as ambulatory care sensitive conditions (ACSCs), were identified. The chi-square test was used to detect differences between admissions for ACSCs and non-ACSCs by demographic, geographical, and administrative factors. Predictors of ACSCs admissions were analysed using univariate and multiple logistic regression.

RESULTS

Of the 8156 hospital records, there were 3884 (48%) ACSCs admissions, of which admissions for urinary tract infections accounted for 31%, followed by diabetes complications (21%). Mean bed-days were 8.26 for non-ACSCs compared with 9.74 for ACSCs (p ≤ 0.001). There were no differences between admissions for ACSCs and non-ACSCs by sex, marital status, region (rural vs metro), and admission source (private accommodation vs residential facility). Culture and language predicted ASCS admission rates in the univariate regression analyses, with ACSC admission rates increasing by 20 and 29% if English was not the preferred language or if an interpreter was required, respectively. Results from the multiple regression analysis confirmed that language was a significant predictor of ACSC admission rates.

CONCLUSIONS

Improved primary health care may help to reduce the most common causes of PPHs for people living with dementia, particularly for those from culturally and linguistically diverse backgrounds.

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.

Spatiotemporal analysis of hospital admissions for primary care-sensitive conditions in women and children in the first 1000 days of life

OBJECTIVE

To analyze the spatiotemporal distribution of hospital admission rates for primary care-sensitive conditions (PCSC) in women and children in the first 1000 days of life in Brazil.

METHODS

Ecological study, with spatiotemporal analyses, using secondary data from Brazilian municipalities. PCSC in women, related to prenatal care and childbirth, and in children under two years old, from 2008 to 2019 were used to characterize trends and formations of spatiotemporal clusters/outliers. Crude PCSC rates were calculated and adjusted by the local empirical Bayesian method, presented in choropleth maps. We also used Anselin Local Moran I type analyses to identify spatial clusters, and space-time cube with clustering by emerging hotspot, followed by time series clustering, for analysis of spatiotemporal trends (alpha = 5%).

RESULTS

A total of 1,850,776 PCSC were registered in pregnant women, puerperae, and children under two years of age in Brazil, representing 1.7% of the total number of hospital admissions in the period. PCSC rates showed different behaviors when the groups of women and children were evaluated, with a predominant growing trend of 109% in admissions in the first group and a reduction of 34.4% in the second. The North, Northeast, and Midwest regions had larger high-risk clusters and more significant increasing trends in PCSC in the two subpopulations studied.

CONCLUSIONS

Health actions and services in primary care may be reducing hospital admissions for children, but they are not being effective in reducing hospital admissions for women for causes related to prenatal care and childbirth, especially in the North, Northeast, and Midwest of Brazil. Investments in the qualification of care over the thousand days are urgent in the country.

Characterizing Potentially Preventable Hospitalizations of High-Cost Patients in Rural China

Introduction

High-cost patients are characterized by repeated hospitalizations, and inpatient cost accounts for a large proportion of their total health care spending. This study aimed to assess the occurrence and costs of potentially preventable hospitalizations and explore contributing factors among high-cost patients in rural China.

Methods

We examined a population-based sample of patients using the 2016 New Rural Cooperative Medical Scheme in Dangyang city, China. Eighteen thousand forty-three high-cost patients were identified. A validated tool and logistic regression analysis were used to determine preventable hospitalizations and their patient-level and supply-side factors.

Results

High-cost patients were older (average age of 54 years) than non-high-cost patients (50 years) and more likely to come from poverty-stricken families. The occurrence of preventable hospitalization was 21.65% among high-cost patients. The proportion of preventable inpatient cost in total inpatient and outpatient expenditure among high-cost patients (5.81%) was lower than that of non-high-cost patients (7.88%) but accounted for 75.87% of the overall preventable inpatient cost. High-cost patients with more hospitalizations were more likely to experience preventable hospitalization, and those with heart failure, COPD, diabetes and mixed conditions were at a higher risk of preventable hospitalization, while those with more outpatient visits were less likely to show preventable hospitalization.

Conclusions

The occurrence of preventable hospitalization among high-cost patients in rural China was sizeable. The preventable inpatient cost of the overall population was concentrated among high-cost patients. Interventions such as improving preventive care and disease management targeting high-cost patients within counties may improve patients' health outcomes and quality of life and reduce overall preventable inpatient cost.