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Rosella LC, Hurst M, O'Neill M, Pagalan L, Diemert L, Kornas K, Hong A, Fisher S, Manuel DG. A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT). Diagn Progn Res 2024; 8:2. [PMID: 38317268 PMCID: PMC10845544 DOI: 10.1186/s41512-024-00165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/15/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION Avoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data. METHODS AND ANALYSIS The derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18-74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Abstract Database (1999/2000-2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000-2006 compared to 2007-2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell's concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement. ETHICS AND DISSEMINATION This study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.
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Affiliation(s)
- Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada.
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada.
- Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
- ICES, Toronto, ON, M4N 3M5, Canada.
| | - Mackenzie Hurst
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
- ICES, Toronto, ON, M4N 3M5, Canada
| | - Meghan O'Neill
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Lief Pagalan
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Lori Diemert
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Andy Hong
- PEAK Urban Research Programme, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Department of City & Metropolitan Planning, University of Utah, Salt Lake City, UT, USA
- The George Institute for Global Health, Newtown, NSW, Australia
| | - Stacey Fisher
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Health Sciences Building 6th Floor, Toronto, ON, M5T 3M7, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Douglas G Manuel
- Ottawa Hospital Research Institute, Ottawa, Canada
- Statistics Canada, Ottawa, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
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Jung HW, Lee WR. Association between initial continuity of care status and diabetes-related health outcomes in older patients with type 2 diabetes mellitus: A nationwide retrospective cohort study in South Korea. Prim Care Diabetes 2023; 17:600-606. [PMID: 37865571 DOI: 10.1016/j.pcd.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/17/2023] [Accepted: 10/08/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND AND AIM Timely and continuous care is necessary for patients with diabetes to prevent hospitalization and complications. This study investigated the association between initial Continuity of Care Index (COCI) status after diagnosis of type 2 diabetes mellitus (T2DM) and short- and long-term diabetes-related health outcomes. METHODS It targeted elderly patients aged 60 years and above diagnosed with T2DM and used the National Health Insurance Service Senior cohort data from 2008 to 2019. The outcome measures were diabetic avoidable hospitalization and diabetic complication incidence for a five-year period. The main independent variable was the first-year COCI status after T2DM diagnosis. Survival analyses were performed using the Cox proportional hazards model. RESULTS Participants with a good COCI status within the first year of being diagnosed with T2DM experienced a reduced risk of diabetes-induced avoidable hospitalization (five years: Hazard ratio (HR) 0.39, 95 % Confidence interval (CI) 0.27-0.57; overall period: HR 0.56, 95 % CI 0.43-0.72) and diabetic complications (five years: HR 0.74, 95 % CI 0.68-0.80; overall period: HR 0.77, 95 % CI 0.71-0.82). CONCLUSIONS In the short- and long-term, there is a need for early management and improved healthcare accessibility of diabetes to prevent diabetes-avoidable hospitalization and diabetes-related complications.
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Affiliation(s)
- Hyun Woo Jung
- Department of Health Administration, Graduate School·BK21 Graduate Program Of Developing Glocal Experts in Health Policy And Management, Yonsei University, Wonju, South Korea
| | - Woo-Ri Lee
- Department of Research and Analysis, National Health Insurance Service Ilsan Hospital, Goyang, South Korea.
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Gwon YG, Han SJ, Kim KH. Trends in the Quality of Primary Care and Acute Care in Korea From 2008 to 2020: A Cross-sectional Study. J Prev Med Public Health 2023; 56:248-254. [PMID: 37287202 DOI: 10.3961/jpmph.23.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/24/2023] [Indexed: 06/09/2023] Open
Abstract
OBJECTIVES Measuring the quality of care is paramount to inform policies for healthcare services. Nevertheless, little is known about the quality of primary care and acute care provided in Korea. This study investigated trends in the quality of primary care and acute care. METHODS Case-fatality rates and avoidable hospitalization rates were used as performance indicators to assess the quality of primary care and acute care. Admission data for the period 2008 to 2020 were extracted from the National Health Insurance Claims Database. Case-fatality rates and avoidable hospitalization rates were standardized by age and sex to adjust for patients' characteristics over time, and significant changes in the rates were identified by joinpoint regression. RESULTS The average annual percent change in age-/sex-standardized case-fatality rates for acute myocardial infarction was -2.3% (95% confidence interval, -4.6 to 0.0). For hemorrhagic and ischemic stroke, the age-/sex-standardized case-fatality rates were 21.8% and 5.9%, respectively in 2020; these rates decreased since 2008 (27.1 and 8.7%, respectively). The average annual percent change in age-/sex-standardized avoidable hospitalization rates ranged from -9.4% to -3.0%, with statistically significant changes between 2008 and 2020. In 2020, the avoidable hospitalization rates decreased considerably compared with the 2019 rate because of the coronavirus disease 2019 pandemic. CONCLUSIONS The avoidable hospitalization rates and case-fatality rates decreased overall during the past decade, but they were relatively high compared with other countries. Strengthening primary care is an essential requirement to improve patient health outcomes in the rapidly aging Korean population.
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Affiliation(s)
- Yeong Geun Gwon
- Review and Assessment Research Division, Health Insurance Review & Assessment Service, Wonju, Korea
| | - Seung Jin Han
- Primary Care Improvement Division, Health Insurance Review & Assessment Service, Wonju, Korea
| | - Kyoung Hoon Kim
- International Policy Research Division, Health Insurance Review & Assessment Service, Wonju, Korea
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Kiadaliri A, Lohmander LS, Dahlberg LE, Englund M. Incipient dementia and avoidable hospital admission in persons with osteoarthritis. Osteoarthr Cartil Open 2023; 5:100341. [PMID: 36798737 PMCID: PMC9926213 DOI: 10.1016/j.ocarto.2023.100341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Ali Kiadaliri
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden,Centre for Economic Demography, Lund University, Lund, Sweden,Corresponding author. Skåne University Hospital, Clinical Epidemiology Unit, Remissgatan 4, SE-221 85 Lund, Sweden.
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Leif E. Dahlberg
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Chen S, Fu H, Jian W. Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018. BMC Health Serv Res 2022; 22:856. [PMID: 35788227 PMCID: PMC9252061 DOI: 10.1186/s12913-022-08275-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Siyuan Chen
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Hullick C, Conway J, Hall A, Murdoch W, Cole J, Hewitt J, Oldmeadow C, Attia J. Video-telehealth to support clinical assessment and management of acutely unwell older people in Residential Aged Care: a pre-post intervention study. BMC Geriatr 2022; 22:40. [PMID: 35012480 PMCID: PMC8744579 DOI: 10.1186/s12877-021-02703-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older people living in Residential Aged Care (RAC) are at high risk of clinical deterioration. Telehealth has the potential to provide timely, patient-centred care where transfer to hospital can be a burden and avoided. The extent to which video telehealth is superior to other forms of telecommunication and its impact on management of acutely unwell residents in aged care facilities has not been explored previously. METHODS In this study, video-telehealth consultation was added to an existing program, the Aged Care Emergency (ACE) program, aiming at further reducing Emergency Department (ED) visits and hospital admissions. This controlled pre-post study introduced video-telehealth consultation as an additional component to the ACE program for acutely unwell residents in RACs. Usual practice is for RACs and ACE to liaise via telephone. During the study, when the intervention RACs called the ED advanced practice nurse, video-telehealth supported clinical assessment and management. Five intervention RACs were compared with eight control RACs, all of whom refer to one community hospital in regional New South Wales, Australia. Fourteen months pre-video-telehealth was compared with 14 months post-video-telehealth using generalized linear mixed models for hospital admissions after an ED visit and ED visits. One thousand two hundred seventy-one ED visits occurred over the 28-month study period with 739 subsequent hospital admissions. RESULTS There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth; adjusted incident rate ratios (IRR) were 0.98 (confidence interval (CI) 0.55 to 1.77) and 0.89 (95% CI 0.53 to 1.47) respectively. CONCLUSIONS Video-telehealth did not show any incremental benefit when added to a structured hospital avoidance program with nursing telephone support. TRIAL REGISTRATION The larger Aged Care Emergency evaluation is registered with ANZ Clinical Trials Registry, ACTRN12616000588493.
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Affiliation(s)
- Carolyn Hullick
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia. .,Belmont Hospital, Hunter New England Local Health District, Belmont, Australia. .,Hunter Medical Research Institute, New Lambton Heights, Australia.
| | - Jane Conway
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Alix Hall
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Wendy Murdoch
- Belmont Hospital, Hunter New England Local Health District, Belmont, Australia
| | | | - Jacqueline Hewitt
- Hunter New England Central Coast Primary Health Network, Newcastle West, Australia
| | | | - John Attia
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,John Hunter Hospital, Hunter New England Health, Locked Bag 1, HRMC, New Lambton Heights, NSW, 2310, Australia
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Lavoie JG, Philips-Beck W, Kinew KA, Kyoon-Achan G, Sinclair S, Katz A. The relationship between rates of hospitalization for ambulatory care sensitive conditions and local access to primary healthcare in Manitoba First Nations communities : Results from the Innovation in Community-based Primary Healthcare Supporting Transformation in the Health of First Nations in Manitoba (iPHIT) study. Can J Public Health 2021; 112:219-230. [PMID: 33125638 PMCID: PMC7910355 DOI: 10.17269/s41997-020-00421-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 09/15/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The objective of this study was to assess the performance of models of primary healthcare (PHC) delivered in First Nation and adjacent communities in Manitoba, using hospitalization rates for ambulatory care sensitive conditions (ACSC) as the primary outcome. METHODS We used generalized estimating equation logistic regression on administrative claims data for 63 First Nations communities from Manitoba (1986-2016) comprising 140,111 people, housed at the Manitoba Centre for Health Policy. We controlled for age, sex, and socio-economic status to describe the relationship between hospitalization rates for ACSC and models of PHC in First Nation communities. RESULTS Hospitalization rates for acute, chronic, vaccine-preventable, and mental health-related ACSCs have decreased over time in First Nation communities, yet remain significantly higher in First Nations and remote non-First Nations communities as compared with other Manitobans. When comparing different models of care, hospitalization rates were historically higher in communities served by health centres/offices, whether or not supplemented by itinerant medical services. These rates have significantly declined over the past two decades. CONCLUSION Local access to a broader complement of PHC services is associated with lower rates of avoidable hospitalization in First Nation communities. The lack of these services in many First Nation communities demonstrates the failure of the current Canadian healthcare system to meet the need of First Nation peoples. Improving access to PHC in all 63 First Nation communities can be expected to result in a reduction in ACSC hospitalization rates and reduce healthcare cost.
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Affiliation(s)
- Josée G Lavoie
- Department of Community Health Science, University of Manitoba, 715-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada.
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada.
| | - Wanda Philips-Beck
- Department of Community Health Science, University of Manitoba, 715-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | - Kathi Avery Kinew
- Department of Community Health Science, University of Manitoba, 715-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | - Grace Kyoon-Achan
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | - Stephanie Sinclair
- First Nations Health and Social Secretariat of Manitoba, Winnipeg, Canada
| | - Alan Katz
- Department of Community Health Science, University of Manitoba, 715-727 McDermot Avenue, Winnipeg, MB, R3E 3P5, Canada
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Canada
- Department of Family Medicine, University of Manitoba, Winnipeg, Canada
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Yeh CM, Chou YJ, Lin SK, Liu CJ, Huang N. Patient-sharing relationship between Chinese medicine doctors and other physicians: costs and outcomes of breast cancer survivorship care. J Cancer Surviv 2021; 15:922-932. [PMID: 33599958 DOI: 10.1007/s11764-020-00985-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/21/2020] [Indexed: 01/03/2023]
Abstract
PURPOSE Breast cancer survivors represent a unique group of patients who need complex and continuous care after their cancer treatment. These patients often see several providers in various specialties. This study aimed to analyze how traditional Chinese medicine (TCM) integration within care networks of patients with breast cancer might be related to health care costs and patient outcomes under the National Health Insurance program in Taiwan. METHODS We enrolled all patients who underwent definitive mastectomy for newly diagnosed breast cancer between 2007 and 2015. We analyzed the presence of TCM physicians and the patient-sharing relationship between TCM physicians and other physicians during the first year after mastectomy. The outcomes included all-cause mortality, avoidable hospitalization, and medical expenditures. RESULTS There were 68,987 patients with breast cancer, with a median age of 53 years. After propensity score matching, patients whose TCM doctors had the highest connectedness with other physicians had the lowest odds of avoidable hospitalization (adjusted odds ratio 0.86; 95% confidence interval [CI], 0.78-0.96) and lowest hazard of mortality (adjusted hazard ratio, 0.82; 95% CI, 0.72-0.93), followed by those with TCM doctors with medium connectedness, then low connectedness, and lastly those patients with no TCM doctor in their care network. CONCLUSIONS A dose-response pattern was observed regarding the relationship between TCM doctor's connectedness with other physicians within a patient's care network and patient outcomes. IMPLICATIONS FOR CANCER SURVIVORS The findings demonstrated that stronger connectedness between TCM and other physicians could help improve the health outcomes of breast cancer survivors.
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Affiliation(s)
- Chiu-Mei Yeh
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shun-Ku Lin
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Department of Chinese medicine, Taipei City Hospital, Renai Branch, Taipei, Taiwan
- General Education Center, University of Taipei, Taipei, Taiwan
| | - Chia-Jen Liu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Nicole Huang
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan.
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Lavoie JG, Wong ST, Ibrahim N, O’Neil JD, Green M, Ward A. Underutilized and undertheorized: the use of hospitalization for ambulatory care sensitive conditions for assessing the extent to which primary healthcare services are meeting needs in British Columbia First Nation communities. BMC Health Serv Res 2019; 19:50. [PMID: 30658626 PMCID: PMC6339420 DOI: 10.1186/s12913-018-3850-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/19/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Since the 1960s, the federal government has been providing or funding a selection of community-based primary healthcare (PHC) programs on First Nations reserves. A key question is whether local access to PHC can help address health inequities in First Nations on-reserve communities in British Columbia (BC). OBJECTIVES This paper examines whether hospitalization for Ambulatory Care Sensitive Conditions (1) can be used as a proxy measure for the organization of PHC in First Nations reserve areas; and (2) is associated with premature mortality rates. METHODS In this descriptive correlational study, we used administrative data available through Population Data BC, including demographic and ecological information (i.e. geo-codes indicating location of residence). We used two different measures of hospitalization: rates of episodic hospital care and rates of length of stay. We correlated hospitalization rates with premature mortality rates and the level of care available in First Nations communities, which depends on a federal funding formula based upon community size and, more specifically, the level of isolation from a provincial point of care. RESULTS First Nations communities in BC that have local 24/7 access to PHC services have similar rates of hospitalization for ACSC to those living in urban centres. This is demonstrated by the similarities in the strengths of the correlation between premature mortality rates and rates of avoidable hospitalization for conditions treatable in a PHC setting. This is not the case for communities served by a Health Centre (weaker correlation) and for communities serviced by a Health Station or with no on-reserve point of care (no correlation). CONCLUSIONS Improving access to PHC services in First Nations communities can be associated with a significant reduction in avoidable hospitalization and premature mortality rates. The method we tested is an important tool that could serve health care planning decisions in small communities.
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Affiliation(s)
- Josée G. Lavoie
- Dept of Community Health Sciences, University of Manitoba, #715 – 727 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada
| | - Sabrina T. Wong
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Naser Ibrahim
- Ongomiizwin Research, University of Manitoba, Winnipeg, Canada
| | | | | | - Amanda Ward
- First Nation Health Authority, Vancouver, Canada
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Bardin A, Dalla Zuanna T, Favarato S, Simonato L, Zanier L, Comoretto RI, Canova C. The Role of Maternal Citizenship on Pediatric Avoidable Hospitalization: A Birth Cohort Study in North-East Italy. Indian J Pediatr 2019; 86:3-9. [PMID: 30637678 DOI: 10.1007/s12098-018-2826-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/16/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Avoidable hospitalization (AH) has been widely studied as a possible measure of primary health care performance. Since studies evaluating AH in migrant children, particularly in Europe, are lacking, the aim of this study was to investigate the role of maternal citizenship on the risk of AH in children. METHODS The cohort study included all live newborns recorded in the Medical Birth Register (MBR) of Friuli-Venezia Giulia Region (Italy) in the years 1989-2012, followed from 30 d after their birth up to the 14th year of life. Cox regression models were used to estimate Hazard Ratios (HRs) for any AH and for specific conditions. RESULTS Among the 213,635 children included in the cohort, authors identified 23,011 AHs in 16,744 children, most of which occurred between 1 and 4 y of age. Children born to mothers from High Migration Pressure Countries had a higher risk of AH for any condition (HR 1.35; 95% CI = 1.27-1.44) than children born to Italian mothers. The risks were higher concerning gastroenteritis (HR 1.74; 1.57-1.94), upper respiratory tract infections (HR 1.58; 1.35-1.84), asthma (HR 1.53; 1.12-2.06) and bacterial pneumonia (HR 1.18; 1.01-1.37). There were no differences in urinary tract infections, short term complications of diabetes and perforated appendix. CONCLUSIONS Despite the inclusiveness and universality of the Italian healthcare system, children born to immigrant mothers experienced more need of avoidable hospital care than children born to Italian mothers. Access barriers to primary care are plausible causes for the observed disparities.
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Affiliation(s)
- Andrea Bardin
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Teresa Dalla Zuanna
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Susanna Favarato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Lorenzo Simonato
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Loris Zanier
- Epidemiological Service, Health Directorate, Friuli Venezia-Giulia Region, Udine, Italy
| | - Rosanna Irene Comoretto
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Cristina Canova
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy.
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Lin IP, Wu SC. Effects of long-term high continuity of care on avoidable hospitalizations of chronic obstructive pulmonary disease patients. Health Policy 2017; 121:1001-7. [PMID: 28751032 DOI: 10.1016/j.healthpol.2017.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 06/08/2017] [Accepted: 06/27/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine the effects of high continuity of care (COC) maintained for a longer time on the risk of avoidable hospitalization of patients with chronic obstructive pulmonary disease (COPD). METHODS A retrospective cohort study design was adopted. We used a claim data regarding health care utilization under a universal health insurance in Taiwan. We selected 2199 subjects who were newly diagnosed with COPD. We considered COPD-related avoidable hospitalizations as outcome variables. The continuity of care index (COCI) was used to evaluate COC as short- and long-term COC. A logistic regression model was used to control for sex, age, low-income status, disease severity, and health status. RESULTS Long-term COC had stronger effect on health outcomes than short-term COC did. After controlling for covariables, the logistic regression results of short-term COC showed that the medium COCI group had a higher risk of avoidable hospitalizations (adjusted odds ratio [AOR]: 1.89, 95% CI: 1.07-3.33) than the high COCI group did. The results of long-term COC showed that both the medium (AOR: 1.98, 95% CI: 1.0-3.94) and low (AOR: 2.03, 95% CI: 1.05-3.94) COCI groups had higher risks of avoidable hospitalizations than did the high COCI group. CONCLUSIONS Maintaining long-term high COC effectively reduces the risk of avoidable hospitalizations. To encourage development of long-term patient-physician relationships could improve health outcomes.
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Hatam N, Fanusi T, Dehghani M, Vojdani R, Ramzi M, Askarian M. Economic Burden of Avoidable Hospitalizations among Patients with Cancer at Namazi Hospital in Shiraz, 2013. Asian Pac J Cancer Prev 2017; 18:177-182. [PMID: 28240514 PMCID: PMC5563097 DOI: 10.22034/apjcp.2017.18.1.177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction: Hospitalization of patients with cancer has a significant economic impact and avoidance where
unnecessary has great potential for significant cost savings for patients, individual hospitals and the health system in
general. Methods: Demographic, clinical and economical data were collected from medical records in our hospital
retrospectively. Oncology clinicians reviewed medical records to categorize each hospitalization as “potentially
avoidable” or “not avoidable.” Patient demographic and clinical data were abstracted and quantitative and qualitative
analyses were performed to identify patient characteristics and outcomes associated with potentially avoidable
hospitalizations. Finally data on the cost of the latter were estimated. Results: Of 451 hospitalizations, medical
oncologists identified 55 (12.2%) as potentially avoidable. Avoiding these and caring for the patients in alternative
locations would save some $ US 641,240 yearly. Among patients with avoidable hospitalization, 70.9% were males
and the median age and median length of stay was 55 years and 4.7 days. Most of them had general signs (83.6%) and
a fever body temperature lower than 38.5’C (96.4%). Lung, kidney and urinary tract cancers were the most common
diagnoses (10.9%). The majority of avoidable hospitalized patients had local cancer (85.5%) and poor performance
status (43.6%). The most prevalent procedure for patients with avoidable hospitalization was sonography and the least
frequent were laboratory tests and MRI. Most cases received no treatment. Conclusion: Avoidable hospitalizations are
common in patients with cancer. Age, final results of hospitalization and length of stay were established as significant
variables for patients with avoidable hospitalization.
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Affiliation(s)
- Nahid Hatam
- Department of Health Service Administration, School of Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
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Ferrer APS, Brentani AVM, Sucupira ACSL, Navega ACB, Cerqueira ES, Grisi SJFE. The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services--Brazilian evidence. Health Policy Plan 2016; 29 Suppl 2:ii107-13. [PMID: 25274635 PMCID: PMC4202922 DOI: 10.1093/heapol/czu077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Brazil is experiencing a time of change in pattern of care: from ‘traditional’ to Family Health Strategy (FHS), a model guided by the principles of people, family and community-centred medicine. The heterogeneity in care currently offered affects the primary care impact. This study aims to evaluate the longitudinality of care and correlate this primary care principle to the utilization pattern of care among patients hospitalized due to preventable conditions, comparing the two care models currently offered in Brazil. It is a cross-sectional, analytical and descriptive study with a quantitative approach. The sample consisted of 501 patients from 0 to 14 years old. Data was collected in 2011 and the Primary Care Assessment Tool (PCATool-Brazil) child version was used. Bivariate and multivariate analyses were performed including patient-related variables (age, maternal education, income and type of diagnosis) and care model. From the hospitalizations occurred during the period, 65.2% were Ambulatory Care Sensitive Conditions. Patients evaluated ‘longitudinality’ as regular. Both the care continuity dimension and the utilization pattern of care services showed a link with the care model offered. Findings suggest that the FHS care model, based on the assumptions of people-centred medicine, was associated with better ratings of care continuity, which was reflected in a more appropriate utilization pattern of care services.
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Affiliation(s)
- Ana Paula Scoleze Ferrer
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
| | - Alexandra Valéria Maria Brentani
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
| | - Ana Cecília Silveira Lins Sucupira
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
| | - Ana Carolina Barsaglini Navega
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
| | - Elisa Scanavini Cerqueira
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
| | - Sandra Josefina Ferraz Ellero Grisi
- Department of Pediatrics, School of Medicine, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar, 647., 05403-000 São Paulo, SP, Brazil
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Abstract
OBJECTIVE Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. DESIGN Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. SETTING A total of 23 countries. SUBJECTS General practitioners and patients. MAIN OUTCOME MEASURES Diabetes-related avoidable hospitalizations. RESULTS Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. CONCLUSIONS Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations. KEY POINTS Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization. Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications. Continuity of care was associated with lower rates of diabetes-related hospitalization. Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.
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Affiliation(s)
- Tessa Van Loenen
- CONTACT T. van Loenen, MSc Radboud University Medical Center, PO Box 9101, 114 IQ Healthcare, 6500 HB Nijmegen, The Netherlands
| | - Marjan J. Faber
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Gert P. Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
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Abstract
OBJECTIVE We aim to examine the relationships between substance use disorders and preventable hospitalizations for Ambulatory Care Sensitive Conditions among adult Medicaid beneficiaries. METHODS Cross-sectional analysis using de-identified Medicaid claims data in 2012 from 177,568 beneficiaries in Missouri was conducted. Logistic regression models were estimated for the associations of substance use disorder status with Ambulatory Care Sensitive Conditions, demographics, chronic physical and mental illnesses. Zero-inflated negative binomial regressions assessed substance use disorders, hospitalization for Ambulatory Care Sensitive Conditions, and length of hospital stay for Ambulatory Care Sensitive Conditions adjusting for co-morbid physical illnesses, mental illnesses and demographics. RESULTS Over 12% of the sample had been diagnosed for substance use disorder. Beneficiaries with substance use disorder were more likely than Nonsubstance use disorder beneficiaries to have admissions for chronic conditions including short/long-term complications of diabetes, uncontrolled diabetes, hypertension, chronic obstructive pulmonary disease/asthma, but not for acute conditions. While substance use disorder beneficiaries were more likely than Nonsubstance use disorder beneficiaries to be hospitalized for any Ambulatory Care Sensitive Conditions; there were no statistical differences between the two groups in terms of length of hospital stays. CONCLUSIONS Substance use disorder is statistically associated with hospitalizations for most Ambulatory Care Sensitive Conditions but not with length of hospital stay for Ambulatory Care Sensitive Conditions, after adjusting for covariates. The significant associations between substance use disorder and Ambulatory Care Sensitive Condition admissions suggest unmet primary health care needs for substance use disorder beneficiaries and a need for integrated primary/behavioral healthcare.
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Affiliation(s)
- Kit Sang Leung
- MIMH,University of Missouri - St. Louis, 4633 World Parkway Circle, St. Louis, MO 63134-3115, USA
| | - Joe Parks
- MIMH,University of Missouri - St. Louis, 4633 World Parkway Circle, St. Louis, MO 63134-3115, USA; Missouri Department of Social Services, 615 Howerton Court, PO Box 6500, Jefferson City, MO 65102-6500, USA
| | - James Topolski
- MIMH,University of Missouri - St. Louis, 4633 World Parkway Circle, St. Louis, MO 63134-3115, USA
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Kornelius E, Huang CN, Yang YS, Lu YL, Peng CH, Chiou JY. Diabetes-related avoidable hospitalizations in Taiwan. Prim Care Diabetes 2014; 8:330-337. [PMID: 24618275 DOI: 10.1016/j.pcd.2014.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND An avoidable hospitalization (AH) is a condition that could have been prevented through effective treatment in outpatient care. Diabetes is often referred to as an ambulatory care-sensitive condition, and its associated hospitalizations are often referred to as avoidable hospitalizations. There are limited data on avoidable hospitalizations for individuals with diabetes in Taiwan. METHOD We used the National Health Interview Survey (NHIS) dataset to obtain diabetes-related avoidable hospitalizations for subjects aged above 12 years. We included data from 20,826 subjects who had completed the interview between 2004 and 2005. Data were collected from a total of 15,574 people, who had agreed to link their health information to the Taiwan National Health Insurance Research Database, including basic demographic variables, inpatient or outpatient medical events, admission date, discharge date, and diagnosis. The 1005 individuals who self-reported having diabetes or had at least 1 hospitalization or 2 physician service claims for diabetes mellitus with an ICD-9 diagnosis of 250 were included in the analysis. We divided those with diagnosis of diabetes into two groups: never hospitalized and hospitalized. The never hospitalized group served as the control group. We further identified hospitalized subjects with long-term complications due to diabetes (PQI-3) that included ICD-CM codes 250.4-250.9. RESULTS The mean ages of patients with diabetes-related long-term complications in the hospitalized and never hospitalized groups were 65 years and 58 years, respectively (p-value<0.01). More than half (52%) of the patients with diabetes-related long-term complications had a body mass index (BMI) lower than 24. The hospitalized group also had lower educational status compared with that of patients in the never hospitalized group (equal to or lower than elementary school, 63% vs. 50%; junior high school, 23% vs. 14%; equal or higher than senior high school, 14% vs. 36%). Furthermore, hospitalized patients tended to have lower household monthly income, were unmarried, and did not have private medical insurance. There were no significance differences in ethnic composition between the groups. Interestingly, patients with frequent retinal examination, and those with lower body mass index had higher frequency of avoidable hospitalization (p<0.01). CONCLUSION We found that the following factors were associated with a higher frequency of avoidable hospitalization among patients with type 2 diabetes: elderly, male, lower body mass index, lower household income, non-exercise, higher disease comorbidity, and frequent retinal examination.
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Affiliation(s)
- Edy Kornelius
- Department of Endocrinology and Metabolism, Chung-Shan Medical University Hospital, 110th JianGuo North Road, 1st Section, 402 Taichung, Taiwan; Institute of Medicine of Chung-Shan Medical University, Taichung, Taiwan.
| | - Chien-Ning Huang
- Department of Endocrinology and Metabolism, Chung-Shan Medical University Hospital, 110th JianGuo North Road, 1st Section, 402 Taichung, Taiwan; Institute of Medicine of Chung-Shan Medical University, Taichung, Taiwan
| | - Yi-Sun Yang
- Department of Endocrinology and Metabolism, Chung-Shan Medical University Hospital, 110th JianGuo North Road, 1st Section, 402 Taichung, Taiwan; Institute of Medicine of Chung-Shan Medical University, Taichung, Taiwan
| | - Ying-Li Lu
- Department of Endocrinology and Metabolism, Chung-Shan Medical University Hospital, 110th JianGuo North Road, 1st Section, 402 Taichung, Taiwan; Institute of Medicine of Chung-Shan Medical University, Taichung, Taiwan
| | - Chiung-Huei Peng
- Institute of Biotechnology, HungKuang University, 34th Chung Chie Road, Shalu County, Taichung, Taiwan
| | - Jeng-Yuan Chiou
- Chung Shan Medical University, School of Health Policy and Management, 110th JianGuo North Road, 1st Section, Taichung, Taiwan.
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Cartier T, Naiditch M, Lombrail P. [ Avoidable hospitalizations: the sole responsibility of primary care?]. Rev Epidemiol Sante Publique 2014; 62:225-36. [PMID: 25026885 DOI: 10.1016/j.respe.2014.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 01/19/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Avoidable hospitalizations are used as a performance indicator of primary care in many countries. We investigate here the validity and usefulness of this measure both at a global scale and for the French healthcare system. METHODS A scoping study was performed to take a critical look at this concept. The different uses of avoidable hospitalizations as an indicator have already been reported in two recent systematic literature reviews. RESULTS Rates of avoidable hospitalizations seem to be far more correlated with the socioeconomic attributes of patients than with primary care supply. The few studies conducted in France confirm this international trend. Several weaknesses have been spotted in the building of this indicator: the choice of conditions that can be considered as sources of avoidable hospitalizations, their identification among hospitalization disease codes, the quality of hospital coding procedures, the ecological bias in the data collection of illustrative variables. CONCLUSION Guidelines for improvement of this indicator are provided. In particular, we discuss the possibility of its use at the scale of the whole healthcare system.
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Affiliation(s)
- T Cartier
- Institut de documentation et de recherche en économie de la santé, 10, rue Vauvenargues, 75018 Paris, France; Laboratoire éducations et pratiques de santé - EA 3412, UFR SMBH, université Paris-13, Bobigny, France; Département universitaire de médecine générale - UFR SMBH, université Paris-13, Bobigny, France; PROSPERE, 75018 Paris, France.
| | - M Naiditch
- Institut de documentation et de recherche en économie de la santé, 10, rue Vauvenargues, 75018 Paris, France; PROSPERE, 75018 Paris, France
| | - P Lombrail
- Laboratoire éducations et pratiques de santé - EA 3412, UFR SMBH, université Paris-13, Bobigny, France; Groupe hospitalier Paris-Seine-Saint-Denis, AP-HP, Bobigny, France
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