Preventable Hospitalizations: Assessing Access and the Performance of Local Safety Net

1. Preventable Hospitalizations: Assessing Access and the Performance of Local Safety Net Presented by Yu Fang (Frances) Lee Feb. 9th, 2007

2. Outline • Preventable hospitalizations • Connection between local safety net capacity and preventable hospitalizations • Research proposals

3. Preventable Hospitalizations Avoidable Hospitalizations Avoidable Hospital Conditions (AHCs) Ambulatory-Care Sensitive Conditions (ACSCs or ACS Conditions)

4. Inpatient treatments of conditions for which timely and effective use of primary care should have reduced the risk of hospitalizations (Texas Health Care Information Collection, 2003) Preventable Hospitalizations

5. Preventable Hospitalizations • A list of ICD-9-CM codes based on hospital discharge data • Usually measured as rates of admission to the hospitals • Different technical definitions of PH: Billings et al. (1993) Weissman et al. (1992) Agency for Healthcare Research and Quality (AHRQ) – Prevention Quality Indicators

6. Preventable Hospitalizations Resource: http://www.qualityindicators.ahrq.gov

7. PQI 1: Diabetes Short-term Complication Admission Rate Admissions for diabetic short-term complications per 100,000 population • Relationship to quality: Proper outpatient treatment and adherence to care may reduce the incidence of diabetic short-term complications • Population at Risk : Population in Metro Area or county, age 18 years and older • Benchmark : State, regional, or peer group average • lower rates represent better quality care

8. PQI 1: Diabetes Short-term Complication Admission Rate • Numerator: All non-maternal/non-neonatal discharges of age 18 years and older, with ICD-9-CM principal diagnosis code for short-term complications Excluded cases: transfer from other institution MDC 14 (pregnancy, childbirth, and puerperium) • Denominator: Population in Metro Area or county, age 18 years and older

9. Use of Preventable Hospitalizations • To assess quality of health services in the community • To identify unmet community health care needs • To monitor how well complications from a number of common conditions are being avoided in the outpatient setting • To compare the performance of local health care systems across communities Resource:Department of Health and Human Services, & Agency for Health Research and Quality. (2006a). Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions.

10. Preventable Hospitalizations • Strengths minimal requirement for resources comparison across different levels • Weaknesses strong relationship between PHs and SES limited evidence for each PH limited evidence on the effectiveness of treatments in reducing incidence of PH Resource:Department of Health and Human Services, & Agency for Health Research and Quality. (2006a). Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions.

11. Davidson et al’s Framework Community Characteristics Health care Access and Outcomes • Safety-Net population • Uninsured population • Medicaid beneficiaries • Vulnerable populations Potential access Usual source of care • Safety-net Support • Direct government & private support of safety net • Medicaid payment level Low-income population support Medicaid eligibility level Realized access Doctor visits Other health care Health care market Physician supply Managed care penetration Managed care competition Safety-net services Public hospitals Teaching hospitals Community clinics Access outcomes Preventable hospitalizations Other outcome indicators Individual Characteristics Predisposing Need Enabling __ Demographics Perceived Income Social factor Evaluated Health insurance Beliefs Usual source of care Community Characteristics Health care Access and Outcomes • Safety-Net population • Uninsured population • Medicaid beneficiaries • Vulnerable populations • Potential access • Usual source of care • Safety-net Support • Direct government & private support of safety net • Medicaid payment level Low-income population support Medicaid eligibility level • Realized access • Doctor visits • Other health care • Health care market • Physician supply • Managed care penetration • Managed care competition • Safety-net services • Public hospitals • Teaching hospitals • Community clinics • Access outcomes • Preventable hospitalizations • Other outcome indicators Individual Characteristics Predisposing Need Enabling __ Demographics Perceived Income Social factor Evaluated Health insurance Beliefs Usual source of care Resource: Davidson, P. L., Andersen, R. M., Wyn, R., & Brown, E. R. (2004). A framework for evaluating safety-net and other community-level factors on access for low-income populations. Inquiry, 41(1), 21-38

12. Proposal 1: Small-Area Analysis Study population: residents aged 18-64 in Harris County, Texas (2004 ) Unit of Analysis: ZIP code Datasets: Project Safety Net (2004) Texas Health Care Information Collection (2004) Census 2000 Data analysis: linear regression

13. Proposal 1: Small-Area Analysis Objectives: To investigate the rate of preventable hospitalizations by insurance type in Harris County, Texas To investigate the association between the capacity of primary care services and preventable hospitalizations for the low-income population To Investigate the association between the proximity to the nearest primary care services and preventable hospitalizations for the low-income population

14. Safety-net population at ZIP-code level • Uninsurance rate • Poverty level • Age • Gender • Ethnicity Access outcome Preventable hospitalization rate • Safety-net primary care services at ZIP-code level • Availability of primary care providers • Capacity of primary care providers Proposal 1: Local Safety Net and Preventable Hospitalization at ZIP-code level

15. Proposal 2: Multi-Level Analysis Study population: hospitalized, non-elderly (aged 18-64) low-income adults in Harris County, Texas (2004 ) Unit of Analysis: individual as level-one ZIP code as level-two Datasets: Project Safety Net (2004) Texas Health Care Information Collection (2004) Census 2000 Data analysis: Multi-level logistic regression

16. Proposal 2: Multi-Level Analysis Objectives: To learn about the fraction of total variability in preventable hospitalization at the individual level and at the community level for hospitalized, non-elderly low-income adults To analyze the association between the proximity to the nearest safety net clinic and preventable hospitalizations among the low-income population, after controlling for individual characteristics and community characteristics To analyze the association between the capacity of local primary care services and the preventable hospitalization among the hospitalized low-income population, after controlling for individual characteristics and area characteristics

17. Proposal 2: Multi-Level Analysis To compare the relative importance of health insurance and the proximity to the local safety net clinics in reducing the likelihood of preventable hospitalization for the hospitalized low-income, non-elderly adults To estimate the direct costs of preventable hospitalizations in Harris County for all low-income, non-elderly hospitalized population in 2004, and compare the average costs of preventable hospitalization in Harris County with those measured in the existing literature

18. Proposal 2: Local Safety Net and Preventable Hospitalization at Two Different Levels Hospitalized Safety- Net Population Community Characteristics • Population characteristics at zip-code level • Uninsurance rate Education Area income at zip-code level Access Outcome Preventable hospitalization Safety-net Services at zip-code level Primary-care capacity of safety net clinics Individual characteristics Predisposing Enabling Gender Health insurance Age Proximity to the nearest safety-net clinic Race Reference: Davidson, P. L., Andersen, R. M., Wyn, R., & Brown, E. R. (2004). A framework for evaluating safety-net and other community-level factors on access for low-income populations. Inquiry, 41(1), 21-38

19. Summary • Preventable hospitalization rate is based on hospital discharge data • Preventable hospitalization is an access outcome, and is one of the main tools to monitor the local safety net • Individual and community characteristics both contribute to preventable hospitalization