Are rates of potentially preventable hospitalizations increasing or decreasing over time?

Between 1994 and 2003, hospital admission rates increased for five of 16 ambulatory care–sensitive conditions (which might indicate worsening in ambulatory care access or quality for those conditions) and decreased for five conditions (which might indicate improvement in ambulatory care access or quality).

Why is this important?

Ambulatory care–sensitive conditions are those "for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease" (AHRQ 2004). Although hospitalization rates are influenced by socioeconomic factors such as poverty (Blustein et al. 1998), high or increasing rates of potentially preventable hospitalizations might indicate inadequate access to high-quality ambulatory care, including preventive and disease management services (Bindman et al. 1995).

Findings

Among 16 ambulatory care–sensitive conditions measured, rates of hospital admissions (age- and sex-adjusted) increased from 1994 to 2003 for five conditions:

• hypertension (high blood pressure), by 26 percent (10 per 100,000 adults);
• short-term complications of diabetes (such as diabetic ketoacidosis and hyperglycemic coma,) by 20 percent (9 per 100,000 adults);
• chronic obstructive pulmonary disease, by 12 percent (28 per 100,000 adults);
• bacterial pneumonia, by 8 percent (27 per 100,000 population of all ages); and
• urinary tract infections, by 7 percent (10 per 100,000 population of all ages).

On the other hand, rates decreased from 1994 to 2003 for five other conditions:

• angina (chest pain) for which no procedure was performed, by 82 percent (225 per 100,000 adults);
• uncontrolled diabetes without complications, by 42 percent (17 per 100,000 adults);
• pediatric gastroenteritis, by 30 percent (39 per 100,000 children and adolescents);
• perforated appendix, which can result from delays in treatment for acute appendicitis, by 11 percent (38 per 100 admissions for appendicitis); and
• congestive heart failure, by 9 percent (45 per 100,000 adults).

There was no statistically significant change from 1994 to 2003 in rates of hospitalization for the other six conditions measured. However, admission rates fluctuated during this time for some conditions. From 2002 to 2003, admission rates increased significantly for one of the 16 conditions (adult asthma) and decreased significantly for two conditions (angina without procedure and dehydration) (AHRQ 2006).

Implications

Reducing preventable hospitalizations can preserve health care dollars to help fund improvements in ambulatory care. For example, assuming that an average hospital stay costs $5,300 per admission, even a modest 5 percent decrease in hospitalizations for these ambulatory care–sensitive conditions would save more than $1.3 billion in inpatient costs (Kruzikas et al. 2004).

Improvement Ideas and Resources

• Expand affordable and comprehensive health care coverage to the uninsured and enhance access to primary care for the uninsured, underinsured, Medicaid-insured, and medically underserved populations (Bindman et al. 2005; Laditka and Laditka 2004; Parchman and Culler 1999). For example, among low-income and elderly patients in medically underserved counties of one state, those with access to federally qualified community health centers had 21 percent fewer preventable hospitalizations than those without access to such clinics (Epstein 2001).
• Promote the use of recommended preventive care. For example, annual influenza vaccination reduces influenza-related hospitalizations (including pneumonia), saving $17 for every elderly person vaccinated (Jefferson et al. 2005; Maciosek et al. 2006; Nichol et al. 1994).
• Educate patients and parents of children about how to control a chronic condition (Flores et al. 2003). For example, educational interventions for patients with asthma can reduce their risk of hospitalization by 36 percent to 43 percent (Gibson et al. 2003; Smith et al. 2005).
• Increase the use of effective care coordination programs for those with chronic disease. For example, comprehensive discharge planning plus post-discharge support for patients with heart failure reduces hospital readmissions by 25 percent on average, which could prevent 84,000 hospitalizations and save $424 million annually if extended to all Medicare patients (Phillips et al. 2004).

Measure:

• The Agency for Healthcare Research and Quality Prevention Quality Indicators were refined through a process of technical and expert review led by the University of California, San Francisco–Stanford University Evidence-Based Practice Center (AHRQ 2004).
• The denominator is the U.S. population of specified ages, except that for perforated appendix and low-birthweight births it is admissions (as indicated). The numerator is the number of admissions with the principal diagnosis for the indicated condition, except that perforated appendix, low birthweight, and amputations could be coded in any field. Rates were age- and sex-adjusted to the 2000 U.S. standard population. Rates exclude transfers from another institution and (except for low-birthweight infants) obstetric and neonatal admissions.
• The percentage and absolute changes in rates described in the Findings may differ slightly from apparent differences in rates shown on the charts because of rounding.

Limitations:

The rates shown include all hospitalizations for a given condition and do not indicate what proportion of the hospitalizations might be preventable through health care interventions versus those that might be attributable to socioeconomic factors such as poverty that must be addressed through broader public policy interventions. The decrease in the rate of admissions for angina for which procedures were not performed would not indicate an improvement to the degree that it was offset by any increase in admissions for angina for which procedures were performed.

Source:

Weighted national estimates are from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS), based on hospital administrative data collected from hospitals by statewide data organizations (AHRQ 2006).

References:

* Indicates source of data used in the chart(s).

AHRQ (Agency for Healthcare Research and Quality). 2004. AHRQ Quality Indicators: Guide to Prevention Quality Indicators. Hospital Admission for Ambulatory Care Sensitive Conditions. Rockville, Md.: U.S. Department of Health and Human Services. * AHRQ (Agency for Healthcare Research and Quality). 2006. HCUPnet: Healthcare Cost and Utilization Project. Rockville, Md.: U.S. Department of Health and Human Services. Bindman, A. B., A. Chattopadhyay, D. H. Osmond et al. 2005. The Impact of Medicaid Managed Care on Hospitalizations for Ambulatory Care Sensitive Conditions. Health Services Research 40 (1): 19–38. Bindman, A. B., K. Grumbach, D. Osmond et al. 1995. Preventable Hospitalizations and Access to Health Care. Journal of the American Medical Association 274 (4): 305–11. Blustein, J., K. Hanson, and S. Shea. 1998. Preventable Hospitalizations and Socioeconomic Status. Health Affairs (Millwood) 17 (2): 177–89. Epstein, A. J. 2001. The Role of Public Clinics in Preventable Hospitalizations Among Vulnerable Populations. Health Services Research 36 (2): 405–20. Flores, G., M. Abreu, C. E. Chaisson et al. 2003. Keeping Children Out of Hospitals: Parents' and Physicians' Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided. Pediatrics 112 (5): 1021–30. Gibson, P. G., H. Powell, J. Coughlan et al. 2003. Self-Management Education and Regular Practitioner Review for Adults with Asthma. Cochrane Database of Systematic Reviews (1): CD001117. Jefferson, T., D. Rivetti, A. Rivetti et al. 2005. Efficacy and Effectiveness of Influenza Vaccines in Elderly People: A Systematic Review. Lancet 366 (9492): 1165–74. Kruzikas, D. T., H. J. Jiang, D. Remus et al. 2004. Preventable Hospitalizations: A Window into Primary and Preventive Care, 2000. AHRQ Pub. No. 04-0056. Rockville, Md.: Agency for Healthcare Research and Quality. Laditka, J. N., and S. B. Laditka. 2004. Insurance Status and Access to Primary Health Care: Disparate Outcomes for Potentially Preventable Hospitalization. Journal of Health and Social Policy 19 (2): 81–100. Maciosek, M. V., L. I. Solberg, A. B. Coffield et al. 2006. Influenza Vaccination: Health Impact and Cost Effectiveness Among Adults Aged 60 to 64 and 65 and Older. American Journal of Preventive Medicine (forthcoming). Nichol, K. L., K. L. Margolis, J. Wuorenma et al. 1994. The Efficacy and Cost Effectiveness of Vaccination Against Influenza Among Elderly Persons Living in the Community. New England Journal of Medicine 331 (12): 778–84. Parchman, M. L., and S. D. Culler. 1999. Preventable Hospitalizations in Primary Care Shortage Areas. An Analysis of Vulnerable Medicare Beneficiaries. Archivew of Family Medicine 8 (6): 487–91. Phillips, C. O., S. M. Wright, D. E. Kern et al. 2004. Comprehensive Discharge Planning with Postdischarge Support for Older Patients with Congestive Heart Failure: A Meta-Analysis. Journal of the American Medical Association 291 (11): 1358–67. Smith, J. R., M. Mugford, R. Holland et al. 2005. A Systematic Review to Examine the Impact of Psycho-Educational Interventions on Health Outcomes and Costs in Adults and Children with Difficult Asthma. Health Technology Assessment 9 (23): 1–182.