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

Article Figures & Data

Tables

  • Table 1

    Characteristics of Primary Care Physicians and Patients

    CharacteristicsValue
    Physicians, No.12
    Age, mean (SD), y54 (8)
    Female, No. (%)3 (25)
    Work experience, mean (SD), y18 (10)
    Working in solo practice, No. (%)5 (42)
    Location of practice, No. (%)
     Urban5 (42)
     Suburban4 (33)
     Rural3 (25)
    Patients, No.81
    Age, mean (SD), y74 (11)
    Female, No. (%)44 (54)
    Hospital admissions in 2008, mean (SD), No.2.22 (1.30)
    Hospitalizations for ACSCs in 2008, mean (SD), No.0.94 (0.56)

    • ACSC=ambulatory care–sensitive condition.

  • Table 2

    Primary Care Physicians’ Ratings of Ambulatory Care–Sensitive Hospitalizations (N=104)

    Attributed CausesaPotentially Avoidable No. (%)Not Avoidable No. (%)
    Total43 (41)61 (59)
    System level19 (63)11 (37)
     Absence of treating physician7 (70)3 (30)
     Unavailability of ambulatory services5 (50)5 (50)
     Failure to utilize ambulatory services7 (88)3 (12)
    Physician level12 (38)20 (62)
     Diagnostic uncertainty2 (25)6 (75)
     Ambulatory treatment failure4 (24)13 (76)
     Suboptimal monitoring6 (86)1 (14)
    Medical19 (19)82 (81)
     Medication side effects1 (17)5 (83)
     Medical emergency0 (0)33 (100)
     Somatic comorbidity9 (24)29 (76)
     Psychiatric comorbidity3 (33)6 (67)
     Substance abuse2 (33)4 (67)
     Fall4 (44)5 (56)
    Patient level45 (54)38 (46)
     Fearfulness7 (64)4 (37)
     Cultural background5 (56)4 (45)
     Insufficient language skills6 (67)3 (33)
     Delayed help seeking5 (71)2 (29)
     Medication error4 (100)0
     Medication nonadherence11 (52)10 (48)
     Nonmedication nonadherence6 (38)10 (63)
     Cognitive impairment1 (17)5 (83)
    Social level9 (45)11(55)
     Lack of social support5 (46)6 (55)
     Overprotective caregiver3 (75)1 (25)
     Overstrained caregiver1 (20)4 (80)

    • ↵a Multiple causes could be attributed to each ambulatory care–sensitive hospitalization.

  • Table 3

    Implications for Primary Care Practice and Policy

    Implications for primary care practice teams
    Identification of patients at high risk for hospitalization for ACSCs by complementing predictive modeling with assessment of patients’ social situation, medication adherence, and self-management capabilities
    Regular medication review (what medication is taken and how?), easy-to-read medication schedules, and shared treatment plan among patients, caregivers, and physicians to improve adherence
    Regular (telephone-) monitoring of symptoms and treatment adherence in high-risk patients
    Self-management training of patients and caregivers (eg, should enable them to manage acute deterioration or to seek timely help of primary care resources)
    Identification of existing social support systems (eg, family, friends, neighbors) and community resources
    Health technology systems (eg, recall system for monitoring, updated links to community resources and ambulatory services, shared medical records between primary care practices and hospitals/after-hours care)
    Enhanced communication between physicians across sectors (eg, treating physicians and external physicians in after-hours care, admission and discharge management, easy access to colleagues to ask for advice in case of diagnostic uncertainty)
    Implication for policy and management
    Accountability for hospitalization is shared across all sectors, including primary care, secondary care, hospitals, communities, and patients
    Hospitalizations for ACSCs do not automatically reflect poor quality of care and should be measured either on a highly aggregated level (large geographic areas) or with sufficient adjustment for its complex causality
    Selection of defined ACSCs that may in future be refined to primary care–sensitive conditions based on evidence rather than expert view
    Communication skills including cultural-sensitive medicine may be emphasized in physician education and training

    • ACSC=ambulatory care–sensitive condition.

Additional Files

  • The Article in Brief

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

    Tobias Freund , and colleagues

    Background Reducing avoidable hospitalizations lowers health care spending and improves both quality of care and quality of life. Hospitalizations for conditions that can typically be managed effectively on an outpatient basis (ambulatory care - sensitive hospitalizations) are potentially avoidable by optimal primary care. This study examines how primary care physicians rate these hospitalizations and whether and how they can be avoided.

    What This Study Found Primary care physicians consider most ambulatory care - sensitive hospitalizations potentially avoidable, attributing the causes to 5 possible categories: system-related causes (eg, unavailable outpatient services), physician-related causes (eg, suboptimal monitoring), medical causes (eg, medication side effects), patient-related causes (eg, delayed help seeking) and social causes (eg, lack of social support). System-related causes aare attributed to 30 hospitalizations (29 percent), physician-related causes to 32 (31 percent), medical causes to 101 (97 percent), patient-related causes to 83 (80 percent), and social causes to 20 (19 percent).

    Implications

    • Strategies to avoid such hospitalizations include after-hours care, optimal use of outpatient services, intensified monitoring of high-risk patients, and initiatives to improve patients' willingness and ability to seek timely help as well as patients' medication adherence.

  • Supplemental Table

    Supplemental Table 1. List of ICD 10-GM Codes Used to Identify Hospitalizations for Ambulatory Care-Sensitive Conditions

    Files in this Data Supplement:

  • Annals Journal Club

    Jul/Aug 2013: Avoiding Hospitalizations for Ambulatory Care-Sensitive Conditions


    The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Article for Discussion

    • Freund T, Campbell SM, Geissler S, et al. Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions. Ann Fam Med. 2013;11(4):363-370.

    Discussion Tips

    Health policy researchers have touted the effect of primary care in helping patients to avoid hospitalizations for ambulatory care-sensitive conditions.2 But how does this happen? This study asks family physician respondents to consider the mechanisms for this important function.

    Discussion Questions

    • What question is asked by this study and why does it matter?
    • How does this study advance beyond previous research and practice on this topic?
    • How strong is the study design for answering the question?
    • Were there sufficiently diverse data sources and perspectives brought to the analysis to give you confidence in the truthfulness and transportability of the findings?
    • What are the main study findings?
    • What factors identified in this study as important to preventing avoidable hospitalizations seem particularly relevant? What others would you add?
    • In your setting, how might you:
      1. Identify and keep track of potentially avoidable hospitalizations (including perhaps readmissions) for ambulatory care-sensitive conditions?
      2. How might you systematically look back at these for things that you might have done to avoid the hospitalization?
      3. How might you take what you are learning and apply it prospectively?
      4. How might you maximize your ongoing learning?
      5. In an era in which hospitals and health care systems may be penalized for readmissions and for avoidable hospitalizations, how might you work with payers and health care system leaders to invest in your efforts to reduce avoidable hospitalizations?
      6. How might you share your methods and emerging findings to maximize your learning?
      7. When might this process cross over from quality improvement to research?
    • How might this study change your practice? Policy? Education? Research?
    • What researchable questions remain?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197.
    2. Rosano A, Loha CA, Falvo R, et al. The relationship between avoidable hospitalization and accessibility to primary care: a systematic review. Eur J Public Health. 2013;23(3):356-360.

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