Typically, we think of the hospital as the patient’s last resort. High costs and the often-stressful environment of these busy facilities’ halls prove unideal for patients, even those of the greatest affluence and especially to those of low-income status. Yet, when access to primary and preventive care in a population is limited, history demonstrates that hospitals step in as the main source for health services, often treating patients well-advanced with illnesses in which the impact could have been limited or sometimes even fully treated given earlier intervention. These conditions commonly include chronic obstructive pulmonary disease, congestive heart failure, bacterial pneumonia, urinary tract infections and complications from diabetes (Fingar, 2015). As a result, it is estimated that 1,294 hospital stays per 100,000 population could be potentially avoided in Virginia with quality outpatient care each year (VDH,2013), draining public and private budgets, medical resources and hospital facility space. Virginia has taken interest in tracking and reducing these avoidable hospital stays as part of the 2016-2020 Plan for Wellbeing’s Goal 4.1 of strengthening the Commonwealth’s primary care system.
Reduction efforts cannot be made however without first understanding the disproportionate prevalence of avoidable hospital stays among different demographics. Nationally, avoidable hospital stays are very much associated with low-income status, geographic location and race as summarized below:
- The highest quarter income bracket has half the number of avoidable stays that the lowest income bracket has (AHRQ, 2013)
- Corresponding to income, 9.9% of all uninsured hospitalizations are potentially avoidable while only 5.4% of privately insured hospitalizations are (Stranges and Stocks, 2008)
- While metropolitan areas average 1,566 avoidable hospitalizations per 100,000 population, remote rural areas average 2,586 per 100,000 population ( Torio and Andrews, 2014)
- In all income groups, rates of potentially avoidable hospitalizations are higher for blacks than whites (AHRQ, 2013)
Therefore, the story is more than just that better primary care is needed in Virginia, but instead that the disparities that exist in accessing primary care must be addressed.
For low income patients, research finds that both perception and cost barriers limit access to ambulatory and preventive care, which is utilized 45% less among this population. These patients report that they lack transportation to primary care facilities, are unavailable during their operating hours, do not have time to follow up with referrals and, in the case primarily of the uninsured, cannot afford the costs (Green, 2013). Additionally, high rates of diabetes and other chronic disease related to the unhealthy lifestyle associated with poverty contribute to the greater prevalence of avoidable hospitalizations in this group. A 2015 study in Pennsylvania found that 96% of diabetes hospitalizations were preventable (Ma, 2015) and yet diabetes is twice as prevalent in the low income population (Rabi, 2006).
Explaining the difference in rates between metropolitan and rural rates may be both income related factors and limited physical proximity to ambulatory care facilities. However, the disparity by race that exists when controlling for income proves the hardest difference to understand and hints at potential discrimination in the primary care system and the factors that surround benefiting from its services (cost, insurance, patient-acceptance, availability).
While more research is needed to determine the causality of these demographic differences, understanding which populations contribute the most to the problem of avoidable hospitalizations gives the state a narrower focus to assist in their reduction goal. The Virginia Plan for Wellbeing has already provided helpful strategies to improve access to ambulatory care by investing in telemedicine, creating Accountable Care communities to efficiently coordinate care services, integrating different types of care to limit the referral process and introducing a payment structure that incentivizes prevention and management. In addition to this list, given the disparities discussed, increasing low-income transportation options and expanding on health education initiatives regarding elements like nutrition and tobacco use that lead to chronic conditions may also prove useful. Finally, to limit the barrier that cost plays, Medicaid expansion under the ACA is encouraged.
Green, L. Patient, Community and Geographic Characteristics of Patients Hospitalized for Ambulatory Sensative Conditions in the State of New Jersey. 2012. Medical University of South Carolina.
State Health Commissioner Marissa Levine. (2015). Virginia’s Plan for Wellbeing. 34-38. Retrieved February 5, 2018, from http://virginiawellbeing.com/
Ma, Z. Medicaid- Insured and Uninsured Were More Likely to Have Diabetes Emergency/ Urgent Admissions. 2015. The American Journal of Managed Care. https://www.researchgate.net/profile/Zhen-Qiang_Ma/publication/279177139_MedicaidInsured_and_Uninsured_Were_More_Likely_to_Have_Diabetes_EmergencyUrgent_Admissions/links/55b6877008ae9289a08bbc54/Medicaid-Insured-and-Uninsured-Were-More-Likely-to-Have-Diabetes-Emergency-Urgent-Admissions.pdf
Potentially Avoidable Hospitalization 2013. Content last review July 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure3.html.m
Stranges, E., Stocks, C. Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2008. HCUP Statistical Brief #99. November 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb99.pdf
Torio CM (AHRQ), Andrews RM (AHRQ). Geographic Variation in Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2005-2011. HCUP Statistical Brief #178. September 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb178-Preventable-Hospitalizations-by-Region.
Rabi DM, Edwards AL, Southern DA, et al. Association of socio-economic status with diabetes prevalence and utilization of diabetes care services. BMC Health Services Research. 2006;6:124. doi:10.1186/1472-6963-6-124.