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Research ArticleOriginal ResearchA

Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care–Sensitive Conditions

Tobias Freund, Stephen M. Campbell, Stefan Geissler, Cornelia U. Kunz, Cornelia Mahler, Frank Peters-Klimm and Joachim Szecsenyi
The Annals of Family Medicine July 2013, 11 (4) 363-370; DOI: https://doi.org/10.1370/afm.1498
Tobias Freund
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
MD
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  • For correspondence: tobias.freund@med.uni-heidelberg.de
Stephen M. Campbell
2Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom; and University Hospital Heidelberg, Heidelberg, Germany
MA, Econ, PhD
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Stefan Geissler
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
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Cornelia U. Kunz
3Warwick Medical School, University of Warwick, Coventry, United Kingdom
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Cornelia Mahler
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
RN, MA, Dr Sc Hum
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Frank Peters-Klimm
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
MD
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Joachim Szecsenyi
1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany
MD, MSc
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  • Re:Addressing avoidable hospitalizations also important in the US
    Sheila Chang
    Published on: 23 September 2013
  • Addressing avoidable hospitalizations also important in the US
    Jennifer Girard
    Published on: 27 July 2013
  • Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions
    Sarah Purdy
    Published on: 11 July 2013
  • Published on: (23 September 2013)
    Page navigation anchor for Re:Addressing avoidable hospitalizations also important in the US
    Re:Addressing avoidable hospitalizations also important in the US
    • Sheila Chang, Third Year Medical Students
    • Other Contributors:

    This article highlights the value of effective primary care in preventing hospitalizations and assessing what physicians attribute as causes of these potentially avoidable hospitalization. This article also sought to debunk the myth that the majority of hospitalizations can be prevented by primary care, a view that those in the medical field hold often, at least in the United States. Furthermore, the experiences of in...

    Show More

    This article highlights the value of effective primary care in preventing hospitalizations and assessing what physicians attribute as causes of these potentially avoidable hospitalization. This article also sought to debunk the myth that the majority of hospitalizations can be prevented by primary care, a view that those in the medical field hold often, at least in the United States. Furthermore, the experiences of international researcher are useful in noticing patterns that may be applicable in the United States and other countries.

    However, because each healthcare system is unique in its operation and its challenges, background of the German healthcare system would have illuminated the applicability of the study to other healthcare systems, such as that of the United States, where we will be future providers. This context is important to appropriately categorize high-risk patients in other healthcare systems, as factors that contribute to the categorization of ambulatory care-sensitive conditions are dependent upon the type of healthcare system. For example, the availability of after hours care in urgent care clinics in the United States differs significantly from the lack of after hours care in Germany as cited by the authors. The lack of information about costs, access, and obstacles in reaching continuity of care in Germany is also a detracting factor of this article.

    Furthermore, because low risk patients are more likely to have a higher margin of prevention with fewer confounding factors than high-risk patients, identification and comparisons amongst low and moderate-risk patients along with high-risk patients may have served to increase predictive power. On the other hand, high-risk patients comprise a good patient population in which to identify areas where cost savings, quality of life, and quality of care can be greatly improved.

    Additionally, the study design could have impacted the low rate of participation by the physicians (13% of invited practices participation). The lack of participation may have been impacted in part by some physicians feeling uncomfortable about reviewing their own charts for errors. Additionally, the extent of time and involvement required for the components of this study may also have greatly affected the sample size. Having physicians discuss cases that were not their own could have been a better approach to this study design. An interesting method would have been to have a group of physicians assess their own patients compared to physicians assessing patients that were not their own to remove any potential bias, but it would also take away from the personal information that the physician has regarding each patient's situation.

    The word choice of "avoiding" versus potentially "delaying" hospitalizations is important to note. There may be some variability in what physicians define as patient level versus physician level factors. For example, medication error under patient level could be related to physician or pharmacist error or lack of education. Better explanation of many of these components would provide more depth to this article.

    The limitations outlined in this study by the authors, such as the lack of input by the patients, were very much appreciated. The study also points to opportunities to improve assessment of patients' social situations and wider recognition of the various factors affecting patient care quality. This article served to increase awareness of our own roles in patient care and become more aware of how we as future providers can play a role in reducing avoidable hospitalizations, such as following up on the care of patients and emphasizing continuity of care, identifying high-risk patients in the medical record, focusing on targeted treatments for these patients, and emphasizing rapport building. As future providers in the United States, a replication of this study could further our understanding of what could best improve quality of healthcare for our patients.

    Competing interests: ?? None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (27 July 2013)
    Page navigation anchor for Addressing avoidable hospitalizations also important in the US
    Addressing avoidable hospitalizations also important in the US
    • Jennifer Girard, Third Year Medical Students.
    • Other Contributors:

    Freund and colleagues' opening discussion of avoidable hospitalizations among the patients of primary care physicians is clear and understandable. One of our main goals as primary care physicians is to provide primary, secondary and tertiary preventative measures so that disease does not progress to the point of requiring hospitalization. This article sheds light on how well we are accomplishing this task. Forty-one perc...

    Show More

    Freund and colleagues' opening discussion of avoidable hospitalizations among the patients of primary care physicians is clear and understandable. One of our main goals as primary care physicians is to provide primary, secondary and tertiary preventative measures so that disease does not progress to the point of requiring hospitalization. This article sheds light on how well we are accomplishing this task. Forty-one percent of hospitalizations were labeled avoidable, and the authors of this study shed light on the reasons why--including suboptimal care by physicians, lack of ambulatory services and patient level barriers as the majority of potentially avoidable hospitalizations.

    In our journal club we discussed how we as future physicians can rectify avoidable hospitalization due to suboptimal care. Our discussion focused on preventive medicine including prescribing life-saving medicines for hypertension and congestive heart failure, screening for hyperlipidemia and colon cancer, performing timely well woman exams including mammograms and PAP smears, and asking about immunizations including shingles, TDaP and yearly influenza. We also discussed the utility of using electronic medical records to review a patient's preventive medicine needs at each visit and the feasibility of spending one to two minutes at the end of each visit to discuss these matters. Lastly, we discussed utilizing office staff members to follow up with patients that are not scheduling yearly exams especially those with chronic conditions that could require hospitalizations such as angina, coronary artery disease, diabetes, and hypertension.

    We also discussed the need for ambulatory services when a patient's primary care physician is not available. Our discussion focused on the difference between ambulatory care in Germany versus the United States. The question remained: Would the outcome change if this study was done in the United States? Furthermore, would the outcome vary between urban and rural settings?

    Lastly, we discussed the patient level barriers to avoidable hospitalizations. We thought it would be an interesting study to interview not only the physicians, but also the patients, especially in the cases where avoidable hospitalizations were a result of cultural/language barriers, medication errors or non-adherence. Was the patient frustrated with the physician? Did the patient think they were receiving suboptimal care? Did the patient understand their medical condition and understand why they were taking the medications they were prescribed?

    As a group, we agreed that a similar study in both rural and urban areas in the United States would be beneficial in order to indentify attributed causes for avoidable hospitalizations and if they are similar or different to those identified in Germany. As a follow up, it would be interesting to see if addressing the attributed causes for avoidable hospitalizations actually prevents them.

    We would like to thank the authors and the Annals of Family Medicine for providing this article for discussion.

    Competing interests: ?? None declared

    Show Less
    Competing Interests: None declared.
  • Published on: (11 July 2013)
    Page navigation anchor for Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions
    Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions
    • Sarah Purdy, Reader in Primary Health Care

    Dear Sir

    I read the paper Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions by Freund at el (Ann. Fam. Med 2013 11:363-370; doi:10.1370/afm.1498) with interest.

    The need to reduce unnecessary or avoidable hospital admissions is a priority for many health care systems. In the UK both hospitals and primary care are performance managed on this issue, y...

    Show More

    Dear Sir

    I read the paper Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions by Freund at el (Ann. Fam. Med 2013 11:363-370; doi:10.1370/afm.1498) with interest.

    The need to reduce unnecessary or avoidable hospital admissions is a priority for many health care systems. In the UK both hospitals and primary care are performance managed on this issue, yet the evidence for interventions to address this growing challenge is lacking.

    This research is interesting in that physicians only rated 41% of admissions for so called ambulatory care sensitive conditions as avoidable. This raises again the issue of which admissions truly are avoidable?[1]

    Secondly, it is interesting in the breadth of reasons why physicians thought admissions could be avoided. The health care system, clinicians, medical problems and patient factors were all considered to account for substantial numbers of the avoidable admissions. This illustrates the complexity of the problem and is a useful reminder to policy makers of the need to involve all parties in the response to rising admission rates. Simply blaming or altering one part of the system is not helpful or constructive.

    1. Purdy S. Tackling avoidable hospital admissions: improving or compromising quality? Quality in Primary Care, 2012; 4: 243-244.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care–Sensitive Conditions
Tobias Freund, Stephen M. Campbell, Stefan Geissler, Cornelia U. Kunz, Cornelia Mahler, Frank Peters-Klimm, Joachim Szecsenyi
The Annals of Family Medicine Jul 2013, 11 (4) 363-370; DOI: 10.1370/afm.1498

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Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care–Sensitive Conditions
Tobias Freund, Stephen M. Campbell, Stefan Geissler, Cornelia U. Kunz, Cornelia Mahler, Frank Peters-Klimm, Joachim Szecsenyi
The Annals of Family Medicine Jul 2013, 11 (4) 363-370; DOI: 10.1370/afm.1498
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