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Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation.

ABSTRACT: OBJECTIVES:To explore whether hospitalisations for ambulatory care sensitive conditions (ACSCs) are associated with low access to primary care. DESIGN:Observational cohort study over 2008 to 2012 using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. SETTING:English primary and secondary care. PARTICIPANTS:A random sample of 300?000 patients. MAIN OUTCOME MEASURES:Emergency hospitalisation for an ACSC. RESULTS:Over the long term, patients with ACSC hospitalisations had on average 2.33 (2.17 to 2.49) more general practice contacts per 6?months than patients with similar conditions who did not require hospitalisation. When accounting for the number of diagnosed ACSCs, age, gender and GP practice through a nested case-control method, the difference was smaller (0.64 contacts), but still significant (p<0.001).In the short-term analysis, measured over the 6?months prior to hospitalisation, patients used more GP services than on average over the 5?years. Cases had significantly (p<0.001) more primary care contacts in the 6?months before ACSC hospitalisations (7.12, 95%?CI 6.95 to 7.30) than their controls during the same 6?months (5.57, 95%?CI 5.43 to 5.72). The use of GP services increased closer to the time of hospitalisation, with a peak of 1.79 (1.74 to 1.83) contacts in the last 30 days before hospitalisation. CONCLUSIONS:This study found no evidence to support the hypothesis that low access to primary care is the main driver of ACSC hospitalisations. Other causes should also be explored to understand how to use ACSC admission rates as quality metrics, and to develop the appropriate interventions.

SUBMITTER: Vuik SI

PROVIDER: S-EPMC5724125 | biostudies-literature | 2017 Aug

REPOSITORIES: biostudies-literature

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Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation.

Vuik Sabine I SI Fontana Gianluca G Mayer Erik E Darzi Ara A

BMJ open 20170821 8

<h4>Objectives</h4>To explore whether hospitalisations for ambulatory care sensitive conditions (ACSCs) are associated with low access to primary care.<h4>Design</h4>Observational cohort study over 2008 to 2012 using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases.<h4>Setting</h4>English primary and secondary care.<h4>Participants</h4>A random sample of 300 000 patients.<h4>Main outcome measures</h4>Emergency hospitalisation for an ACSC.<h4>Results< ...[more]

PMID: 28827243

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Project description:ObjectivesTo study the interplay between several indicators of social disadvantage and hospitalisations due to ambulatory care-sensitive conditions (ACSC) in 2011─2013. To evaluate whether the accumulation of preceding social disadvantage in one point of time or prolongation of social disadvantage had an effect on hospitalisations due to ACSCs. Four common indicators of disadvantage are examined: living alone, low level of education, poverty and unemployment.DesignA population-based register study.SettingNationwide individual-level register data on hospitalisations due to ACSCs for the years 2011-2013 and preceding data on social and socioeconomic factors for the years 2006─2010.ParticipantsFinnish residents aged 45 or older on 1 January 2011.Outcome measureHospitalisations due to ACSCs in 2011-2013. The effect of accumulation of preceding disadvantage in one point of time and its prolongation on ACSCs was studied using modified Poisson regression.ResultsPeople with preceding cumulative social disadvantage were more likely to be hospitalised due to ACSCs. The most hazardous combination was simultaneously living alone, low level of education and poverty among the middle-aged individuals (aged 45-64 years) and the elderly (over 64 years). Risk ratio (RR) of being hospitalised due to ACSC was 3.16 (95% CI 3.03-3.29) among middle-aged men and 3.54 (3.36-3.73) among middle-aged women compared with individuals without any of these risk factors when controlling for age and residential area. For the elderly, the RR was 1.61 (1.57-1.66) among men and 1.69 (1.64-1.74) among women.ConclusionsTo improve social equity in healthcare, it is important to recognise not only patients with cumulative disadvantage but also-as this study shows-patients with particular combinations of disadvantage who may be more susceptible. The identification of these vulnerable patient groups is also necessary to reduce the use of more expensive treatment in specialised healthcare.

Project description:ImportanceDuring the COVID-19 pandemic, many primary care practices adopted telehealth in place of in-person care to preserve access to care for patients with acute and chronic conditions. The extent to which this change was associated with their rates of acute care visits (ie, emergency department visits and hospitalizations) for these conditions is unknown.ObjectiveTo examine whether a primary care practice's level of telehealth use is associated with a change in their rate of acute care visits for ambulatory care-sensitive conditions (ACSC visits).Design, setting, and participantsThis retrospective cohort analysis used a difference-in-differences study design to analyze insurance claims data from 4038 Michigan primary care practices from January 1, 2019, to September 30, 2020.ExposuresLow, medium, or high tertile of practice-level telehealth use based on the rate of telehealth visits from March 1 to August 31, 2020, compared with prepandemic visit volumes.Main outcomes and measuresRisk-adjusted ACSC visit rates before (June to September 2019) and after (June to September 2020) the start of the COVID-19 pandemic, reported as an annualized average marginal effect. The study examined overall, acute, and chronic ACSC visits separately and controlled for practice size, in-person visit volume, zip code-level attributes, and patient characteristics.ResultsA total of nearly 1.5 million beneficiaries (53% female; mean [SD] age, 40 [22] years) were attributed to 4038 primary care practices. Compared with 2019 visit volumes, median telehealth use was 0.4% for the low telehealth tertile, 14.7% for the medium telehealth tertile, and 39.0% for the high telehealth tertile. The number of ACSC visits decreased in all tertiles, with adjusted rates changing from 24.3 to 14.9 per 1000 patients per year (low), 23.9 to 15.3 per 1000 patients per year (medium), and 27.5 to 20.2 per 1000 patients per year (high). In difference-in-differences analysis, high telehealth use was associated with a higher ACSC visit rate (2.10 more visits per 1000 patients per year; 95% CI, 0.22-3.97) compared with low telehealth practices; practices in the middle tertile did not differ significantly from the low tertile. No difference was found in ACSC visits across tertiles when acute and chronic ACSC visits were examined separately.Conclusions and relevanceIn this cohort study that used a difference-in-differences analysis, the association between practice-level telehealth use and ACSC visits was mixed. High telehealth use was associated with a slightly higher overall ACSC visit rate than low telehealth practices. The association of telehealth with downstream care use should be closely monitored going forward.

Project description:BackgroundThe COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans' ambulatory care experience, specifically access and satisfaction, early in the pandemic.MethodsWe employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 - June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans' perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis.ResultsVeterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers ("The phone would hang up on me") and 9 (33%) reported a lack of provider availability ("They are not reaching out like they used to"). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0-10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)). Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), "I stay inside and away from people").ConclusionsWhile the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis.

Project description:ImportanceThe coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine.ObjectiveTo evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic.Design, setting, and participantsIn this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record.Main outcomes and measuresA successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically.ResultsA total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties.Conclusions and relevanceIn this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.

Project description:ImportancePsychiatric emergency department (ED) visits may be avoidable if individuals have access to adequate outpatient care, but the extent to which individuals use the ED itself as a key point of access is largely unknown.ObjectiveTo describe the extent to which the ED is a first point of contact for mental health care among adults, and identify key factors associated with this outcome.Design, setting, and participantsThis cohort study was conducted from 2010 to 2018 in Ontario, Canada. Using health care administrative data, all individuals aged 16 years and older with an incident psychiatric ED visit were included. Statistical analysis was performed from September 2019 to February 2021.Main outcomes and measuresThe primary outcome was no outpatient mental health or addictions contact in the 2 years preceding the incident ED visit. The study also measured predisposing (age, sex, immigrant status, comorbidity), enabling (neighborhood income, rurality, continuity of primary care), and need factors (diagnosis from incident ED visit) associated with the so-called first-contact ED visits, generating adjusted odds ratios (aORs) and 95% CIs.ResultsThe cohort included 659 084 patients who visited the ED. Among these patients, 340 354 were female individuals (51.6%), and the mean (SD) age was 39.1 (18.5) years. The incident ED visit was a first contact for 298 924 individuals (45.4%). Patients who had increased odds of first-contact ED visits included older individuals (aged 65-84 years vs 16-24 years; aOR, 1.13; 95% CI, 1.12-1.14), male individuals (aOR, 1.14; 95% CI, 1.13-1.15), immigrants (eg, economic class immigrant vs nonimmigrant status: aOR, 1.20; 95% CI, 1.18-1.21), rural residents (aOR, 1.21; 95% CI, 1.20-1.21), and in those with minimal primary care (aOR, 1.68; 95% CI, 1.67-1.69). All diagnoses had a higher likelihood of first-contact ED visits than mood disorders, particularly substance and alcohol use disorders (aOR, 1.66; 95% CI, 1.65-1.68).Conclusions and relevanceThis study's results suggest that nearly half of incident psychiatric ED visits were first-contact visits, which may be avoidable. Targeted efforts to improve outpatient access should focus on populations with risk factors for first-contact ED presentations, including men, older adults, rural residents, those with poor primary care connectivity, and those with substance-related diagnoses.

Project description:BACKGROUND:Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal. METHODS:A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions. RESULTS:After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus. CONCLUSIONS:New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.

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Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation.

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Do hospitalisations for ambulatory care sensitive conditions reflect low access to primary care? An observational cohort study of primary care usage prior to hospitalisation.

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