La Atención Primaria de Salud y las hospitalizaciones por Ambulatory Care Sensitive Conditions en CataluñaPrimary Health Care and hospital admissions due to Ambulatory Care Sensitive Conditions in Catalonia
IntroduccióN
Los Ambulatory Care Sensitive Conditions (Acsc) Son Los CóDigos De DiagnóStico De Alta Hospitalaria Que Pretenden Servir De Medida De Hospitalizaciones Que Se Consideran Potencialmente Evitables. La AtencióN Primaria PodríA Evitar El Ingreso De Los Acsc Mediante Alguna De Las Siguientes Intervenciones Propias De Este Nivel Asistencial: A) PrevencióN Primaria; B) PrevencióN Secundaria, O C) PrevencióN Terciaria Y RehabilitacióN.
Material y métodos
Estudio piloto observacional transversal de 248.174 altas hospitalarias, generadas por 2.248.704 habitantes de 161 Áreas Básicas de Salud (ABS) registradas en el conjunto mínimo básico de alta hospitalaria de Cataluña del año 1996. Se ha utilizado el listado completo de códigos de diagnóstico de ACSC identificados en la literatura. Se han calculado las tasas de hospitalización bruta y estandarizada. Para comparar las tasas de hospitalización entre ABS se ha calculado la razón de hospitalización estandarizada (RHE). El efecto de las variables asociadas a las tasas de hospitalización se ha estudiado mediante la regresión de Poisson.
Resultados
Las hospitalizaciones por ACSC representan el 13% del total de las hospitalizaciones y el 16% de las estancias hospitalarias. Las enfermedades agudas y crónicas de las vías respiratorias bajas son la primera causa de hospitalización para los tres grupos de edad (< 15, 15-64 y ≥ 65). Los grupos de diagnósticos más frecuentes para todas las edades son la patología respiratoria (enfermedades agudas y crónicas de las vías respiratorias bajas y neumonía) y la patología del tracto urinario (pielonefritis/infección del tracto urinario). La patología denominada autolimitada (las infecciones otorrinolaringológicas no graves/infecciones de vías respiratorias altas, las convulsiones febriles infantiles, los problemas dentales y las gastroenteritis) representa más del 10% del total de las hospitalizaciones por ACSC, el 45% de las cuales se presenta en niños. La tasa cruda de hospitalización por ACSC para el conjunto de las ABS estudiadas es de 146,9/10.000, siendo el intervalo de las tasas crudas observadas de 12,4 a 239,9/10.000. El intervalo de la RHE fue de 0,01 a 1,85.
Conclusiones
Las hospitalizaciones por ACSC son un indicador que se considera válido para evaluar la capacidad de resolución global de la Atención Primaria e identifica un volumen de actividad hospitalaria susceptible de cuidados del primer nivel asistencial y, por tanto, potencialmente evitable.
Background
Ambulatory Care Sensitive Conditions (ACSC) are a set of selected codes of hospital discharge diagnosis intended to measure avoidable hospitalisations. Primary Health Care Services may avoid the hospitalisations due to ACSC by applying any of the following interventions, that are characteristics of this level of care: a) primary prevention; b) secondary prevention, and c) tertiary prevention and rehabilitation.
Methods
Observational, cross-sectional pilot study on 248,174 hospital discharges, from a population of 2,248,704 inhabitants in 161 Basic Health Care Units (BHCU), recorded in the minimum basic set of hospital discharge data in Catalonia during 1996. The complete list of diagnostic codes of ACSC, identified in the literature search, has been used. Crude and age-standardised hospitalisation rates have been estimated. Standardised hospitalisation ratio (SHR) has been computed to compare hospitalisation rates between BHCU. To analyse the effect of variables associated with high ACSC admission rates, multivariate analysis has been carried out by means of Poisson’s regression.
Results
Hospitalisation due to ACSC account for 13% of all hospitalisations and 16% of hospital stay days. Acute and chronic diseases of the lower respiratory tract are the first cause of hospitalisation at any age group (< 5, 15-64 and ≥ 65 years). The most common diagnostic groups, for all ages are respiratory disorders (acute and chronic diseases of the lower respiratory tract and pneumonia) and urinary tract conditions (pyelonephritis/urinary tract infection). The so-called self-limited health problems (ear, nose and throat mild infections/infections of the upper respiratory tract, febrile convulsions in children and gastroenteritis) account for more than 10% of all hospitalisations by ACSC, 45% of which occur in children. The overall crude hospitalisation rate by ACSC is 146.9/10,000 inhabitants (range: 12.4/10,000-239.9/10,000). SHR ranges from 0.01 to 1.85.
Conclusions
«Hospital admissions due to ACSC» is a valid indicator to assess global performance of Primary Health Care and it identifies a part of hospital activity that is amenable to be cared for at Primary Health Care level and therefore potentially avoidable.
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Cited by (33)
Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure
2016, Atencion PrimariaComprobar si el proceso asistencial en Atención Primaria de Salud (APS), definido por 7 criterios de correcta atención, influye en el riesgo de hospitalizaciones evitables por Ambulatory Care Sensitive Conditions (ACSH) por insuficiencia cardíaca (IC).
Estudio de casos y controles que analizó el riesgo de hospitalización por IC. Factor de exposición: proceso asistencial de APS.
Área sanitaria de la Comunidad de Madrid (n = 466.901).
Pacientes mayores de 14 años con el registro del diagnóstico de IC en la historia clínica electrónica de APS (n = 3.277) antes del 1 de enero de 2007. Los casos fueron pacientes que ingresaron en el hospital de referencia por IC durante 2007. Los controles no requirieron ingreso.
Riesgo de ACSH por IC relacionado con el proceso asistencial considerado tanto de forma conjunta como por cada uno de los criterios. Diferencias en complejidad clínica mediante Adjusted Clinical Group (ACG).
Doscientos veintisiete ingresos por IC frente a un grupo control de 3.050 pacientes. El peso medio de ACG fue mayor en los casos. Los controles tuvieron mayor cumplimentación de criterios, pero ninguno cumplió los 7. Solo en 2 de los criterios se observó menor riesgo de ACSH. A medida que no se cumplimentaba progresivamente cada criterio, el riesgo de ingresar aumentó (OR = 1,33; IC 95%: 1,19-1,49).
La calidad del proceso asistencial en APS influyó en el riesgo de ingreso por IC.
To determine if the process of care in primary health, affects the risk of avoidable hospitalizations for ambulatory care sensitive conditions (ACSH) for heart failure (HF).
Case-control study analyzing the risk of hospitalization for HF. The exposure
factor was the process of care for HF in primary health.
Health area of the region of Madrid (n=466.901).
There were included all adult patients (14 years or older) with a documented diagnosis of HF in the electronic medical record of primary health (n=3.277). The cases were patients who were hospitalized for HF while the controls did not require admission, during 2007.
risk of ACSH for HF related to the process of care considered both overall and for each separate standard of appropiate care. Differences in clinical complexity of the groups were measured using the Adjusted Clinical Group (ACG) classification system.
227 cases and 3.050 controls. Clinical complexity was greater in cases. The standards of appropriate care were met to a greater degree in the control group, but none of the two groups met all the standards that would define a process of care as fully appropriate. A significantly lower risk of ACSH was seen for only two standards of appropriate care. For each additional standard of appropriate care not met, the probability of admission was significantly greater (OR: 1,33, 95% CI: 1,19-1,49).
Higher quality in the process of care in primary health was associated with a lower risk of hospitalization for HF.
Hospitalizations for primary care-sensitive conditions in a southern Brazilian municipality
2013, Revista da Associacao Medica BrasileiraAnalisar as causas mais frequentes de internações por condições sensíveis à atenção primária (ICSAP) em Juiz de Fora, MG, Brasil, por faixa etária e sexo, nos períodos de 2002 a 2005 e 2006 a 2009.
Trata-se de um estudo descritivo a partir dos dados provenientes do Sistema de Informação Hospitalar (SIH-SUS) e das projeções populacionais do Instituto Brasileiro de Geografia e Estatística (IBGE). As taxas de ICSAP foram calculadas para mil habitantes e as causas mais frequentes analisadas por sexo e faixa etária, comparando-se os dois períodos.
As internações por condições sensíveis à atenção primária em Juiz de Fora apresentaram taxas de 7,74/mil hab. no período entre 2002 e 2005 e 8,81/mil hab. entre 2006 e 2009. As principais causas foram insuficiência cardíaca, doenças cerebrovasculares, angina pectoris, doenças pulmonares e infecções de rins e trato urinário que, em conjunto, representaram 4,9/mil hab. no primeiro período e 5,6/mil hab. no segundo período. A evolução das taxas entre os dois períodos ocorreu de forma distinta por faixa etária e sexo.
O estudo não revelou diferença expressiva na taxa de ICSAP entre os dois períodos. Quanto às causas mais frequentes, foi verificada diminuição das taxas de internações por gastroenterites, asma, hipertensão e doenças cerebrovasculares e incremento das internações por insuficiência cardíaca, doenças pulmonares, epilepsias e infecções de rins e trato urinário que ocorreram de forma distinta por sexo e faixa etária. Os resultados evidenciam a necessidade de se aprofundar a reflexão sobre os determinantes das hospitalizações por causas evitáveis.
To study the most frequent causes of hospitalizations for primary care-sensitive conditions (HPCSC) in the city of Juiz de Fora, MG, Brazil, by age group and gender, over the periods of 2002 to 2005 and of 2006 to 2009.
This was a descriptive study, with data collected from the Hospital Information System of the Unified Health System (Sistema de Informação Hospitalar do Sistema Único de Saúde – SIH-SUS) and from population projections by the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística – IBGE). HPCSC rates were calculated for 1,000 inhabitants, and the most frequent causes were studied by gender and age group, comparing both periods.
HPCSP showed rates of 7.74/1,000 between 2002 and 2005 and 8.81/1,000 between 2006 and 2009. The main causes were heart failure, cerebrovascular diseases, angina pectoris, pulmonary diseases, and kidney and urinary tract infections, which together represented 4.9/1,000 in the first period and 5.6/1,000 in the second period. The evolution of the rates between both periods occurred differently by age group and gender.
The study did not exhibit any remarkable differences in HPCSC rates between the periods. Regarding the most frequent causes, reduced hospitalization rates for gastroenteritis, asthma, high blood pressure, and cerebrovascular diseases were observed, as well as increased hospitalizations for heart failure, pulmonary diseases, epilepsies, and kidney and urinary tract infections; these hospitalizations occurred differently by gender and age group. The results showed that a deep reflection regarding the determinants of hospitalizations for avoidable causes is needed.
Performance assessment of health services in Catalonia (Spain): Evaluation of initial results of the Catalan healthcare service project
2009, Gaceta SanitariaLa medida del desempeño de los servicios sanitarios está recibiendo una mayor atención debido al aumento del gasto sanitario y de las expectativas de la población, y a la necesidad de obtener el máximo rendimiento de los recursos invertidos. En Cataluña, en el año 2005, aprovechando la experiencia previa de la Agència de Salut Pública de Barcelona y del Consorci Sanitari de Barcelona comparando los servicios sanitarios de Barcelona y Montreal, una beca de investigación de la Agència d’Avaluació de Tecnologia i Recerca Mèdiques, y el interés de planificación sanitaria del Departament de Salut, se puso en marcha el proyecto de análisis del desempeño de los servicios sanitarios de Cataluña. El objetivo de este artículo es presentar el desarrollo del proyecto, mostrar algunos ejemplos que ilustran el tipo de información que se ha podido obtener y el tipo de análisis que esta información permite, exponer posibles explicaciones de los resultados presentados y discutir algunas limitaciones e implicaciones. De hecho, el valor añadido de este proyecto es que permite conocer el desempeño del sistema sanitario en la consecución de sus objetivos, establecer un conjunto de indicadores homogeneizados de referencia y ser una pieza clave en el desarrollo de la Central de Resultats del Departament de Salut de la Generalitat de Catalunya.
Performance assessment of healthcare services is receiving greater attention due to increasing health care expenditures, greater expectations among the population, and the need to obtain results from the invested resources. Taking advantage of the existing experience of the Agència de Salut Pública de Barcelona and the Consorci Sanitari de Barcelona, which compared the healthcare services of Barcelona and Montreal, a grant from the Agència d’Avaluació de Tecnologia i Recerca Mèdiques, and the health planning interest of the Departament de Salut, the performance assessment of the Catalan healthcare service project was started in Catalonia in 2005.
This article aims to present the development of the project, to provide some examples that illustrate the kind of numerical and graphical information that could be obtained and the kind of analysis that could be performed, to provide possible explanations for the results shown, and to discuss some limitations and implications. Currently, the added value of this project is that it identifies the extent to which the healthcare system is achieving its objectives, establishes a set of homogeneous indicators that could be used in the future, and is a key tool in the development of the Central de Resultats del Departament de Salut de la Generalitat de Catalunya.
To identify primary care interventions that reduce hospitalisation of people over 65 due to ambulatory care sensitive conditions
2007, Atencion PrimariaEstudiar la percepción de los profesionales de atención primaria (AP) sobre las enfermedades que con mayor frecuencia provocan hospitalizaciones en mayores de 65 años, analizar la concordancia con el listado ACSC (Ambulatory Care Sensitive Conditions) e identificar las intervenciones prioritarias que podrían reducir o evitar dicha hospitalización.
Estudio Delphi con expertos de AP procedentes de 7 centros de salud de Granada durante 2005. Análisis descriptivo del consenso obtenido mediante cuestionarios autoadministrados.
Las enfermedades que causan en mayor medida ingresos en mayores de 65 años son: enfermedad pulmonar obstructiva crónica (EPOC) agudizada, insuficiencia cardíaca descompensada, accidente cerebrovascular y caídas-traumatismos. Las enfermedades analizadas forman parte del listado de ACSC salvo las caídas y los procesos cancerosos. El porcentaje estimado de hospitalizaciones evitables desde AP oscila entre el 20% para procesos cancerosos y el 70% para las descompensaciones diabéticas, y es superior al 50% para la EPOC, las hemorragias digestivas y la diabetes. Las intervenciones prioritarias para disminuir los ingresos hospitalarios abarcan la prevención primaria, el diagnóstico precoz y el tratamiento correcto, con una gran variabilidad en la efectividad y la factibilidad percibida para cada intervención concreta.
Las principales causas de ingresos hospitalarios en mayores de 65 años están incluidas como ACSC. Las actuaciones prioritarias para reducir las hospitalizaciones evitables desde AP son intervenciones mixtas a las que, en su mayor parte, se les atribuye una efectividad y una factibilidad superiores al 50%.
To study how primary care (PC) professionals perceive the pathologies that tend to cause hospitalisation of people over 65 most frequently, and to study their consistency with the list of ACSCs (Ambulatory Care Sensitive Conditions). To identify prior PC interventions that could reduce or prevent hospitalisation due to those pathologies.
A Delphi study with PC experts from 7 health care centres in Granada, Spain, during 2005. A descriptive analysis of the consensus obtained via self-administered questionnaires.
The diseases that cause the bulk of admissions in people over 65 are: acute COPD, non-compensated cardiac failure, cerebro-vascular accident, and falls-traumas. The pathologies analysed form part of the list of ACSCs, with the exception of falls, listed as the fourth cause, and cancer processes, listed as the sixth cause. The hospitalisation rates that could be avoided with prompt and effective PC varies between 20% for cancer processes to 70% for non-compensated diabetes. The rate is over 50% in COPD, digestive haemorrhages, and diabetes. The key interventions for reducing hospitalisations are primary prevention care, early diagnosis, and correct treatment. Effectiveness and feasibility vary widely for each particular intervention.
The principal causes of hospitalisation in people over 65 are included as ACSC. Priority actions to reduce avoidable hospitalisations from PC are multi-modal interventions, the majority of which are over 50% effective and feasible.
Acute gastroenteritis: The cost of an ambulatory care sensitive condition
2007, Anales de PediatriaLa gastroenteritis aguda (GEA) ha sido definida como una condición de hospitalización potencialmente evitable y en la que se recomienda rehidratación oral y reintroducción precoz de la alimentación. A pesar de ello, constituye un motivo de ingreso frecuente. Analizaremos las características de los pacientes, el tratamiento y los costes de los ingresos por GEA en un servicio pediátrico.
Estudio prospectivo observacional de pacientes de 1 mes a 14 años de edad que ingresaron en nuestro hospital por GEA durante un año. Se recogió información sobre clínica, etiología, tratamiento, exploraciones complementarias, estancia hospitalaria y costes asociados al episodio.
La GEA constituyó el 16,5 % (65 ingresos, 62 pacientes) de los ingresos en nuestro servicio con dos picos estacionales (febrero-marzo y agosto). Se aisló microorganismo en el 68,6 % de los pacientes con estudio microbiológico (35 % rotavirus; 31,3% Salmonella; 1,9% Shigella). El uso de rehidratación oral fue muy bajo, pese a que el 74 % de los pacientes tenía deshidrataciones leves. Recibió sueroterapia el 89,2 % de los pacientes y el 20 %, antibioterapia. La estancia global fue de 206 días (media: 3,1 días). El coste médico directo fue de 44.254,74 euros (media: 710,46 euros por paciente, intervalo de confianza del 95 %: 616,37-804,56 euros), siendo el 82,9 % del coste generado por la estancia hospitalaria.
La GEA constituyó una de las primeras causas de hospitalización en nuestro servicio de pediatría. El uso de pautas de rehidratación oral fue bajo. El coste económico y social es considerable.
Acute gastroenteritis (AGE) has been defined as an ambulatory care sensitive condition. The recommended treatment consists of oral rehydration and rapid reintroduction of food. Nevertheless, AGE remains an important cause of hospitalization. The objective of the present study was to analyze the patient characteristics, management, and costs associated with hospitalizations due to AGE in a pediatrics department.
We conducted a prospective observational study of patients aged 1 month to 14 years old admitted to our hospital because of AGE over a 1-year period. Information was collected on clinical presentation, etiology, treatment, tests, length of hospital stay, and costs associated with the episode.
AGE was the cause of admission in 16.5% of our patients (65 episodes, 62 patients) with two seasonal peaks (February-March and August). A causative agent was isolated in 68.6 % of the patients with a stool test (35 % rotavirus, 31.3% Salmonella, 1.9% Shigella). Although 74 % of the patients had mild dehydration, exclusive oral rehydration therapy was provided in very few patients: 89.2 % of the patients were treated with IV therapy and 20 % with antibiotics. The total length of stay was 206 days (mean 3.1 days). The direct medical cost was 44,254.74 € (median 710.46 €/patient, 95 % CI: 616.37-804.56 €) and the main component of this cost (82.9 %) was hospitalization.
AGE was one of the main causes of hospitalization in our department. The use of oral rehydration was low. The economic and social cost was considerable.
Hospitalizations for ambulatory care sensitive conditions in the Region of Murcia (Spain)
2006, Revista de Calidad AsistencialLas ambulatory care sensitive conditions (ACSC) miden la utilización hospitalaria por problemas que se podrían haber prevenido y controlado en atención primaria (AP).
Estudiar la magnitud del problema en la Región de Murcia (RM) y valorar el indicador “Tasa de ACSC” para medir la efectividad de AP.
El Conjunto Mínimo de Datos Básicos (CMBD) 2002 y 2003 de los hospitales públicos de la RM y el padrón de 2003. Listado reducido de códigos ACSC. Número y porcentaje de hospitalizaciones, estancias y fallecimientos por ACSC, tasas brutas y estandarizadas.
Durante los 2 años analizados se produjeron 19.108 altas, 159.180 estancias y 1.396 fallecimientos por ACSC (el 10,13% del total de episodios, el 12,1% de estancias y el 21,2% de las muertes). La tasa bruta fue 75,2 por 10.000. El mayor porcentaje correspondió a enfermedad cardiovascular e hipertensión, seguida de insuficiencia cardíaca y neumonías. Una de las gerencias presenta una razón de tasas con respecto a la menor de 1,08 (intervalo de confianza del 95% de 1,03-1,12). En el ámbito hospitalario el porcentaje de ACSC oscilaba entre el 14,2 y el 7,5%. Por servicios, el mayor porcentaje correspondía a medicina interna, cardiología y cirugía general. Siete grupos relacionados por el diagnóstico agrupaban más del 50% de los casos.
Se observa un importante margen para la mejora en la capacidad de resolución de AP en la RM centrada en el control de enfermedades cardiovasculares e hipertensión, insuficiencia cardíaca y neumonías. Antes de atribuir los resultados a AP, se debería descartar otros factores. Las diferencias en la calidad del CMBD pueden afectar también a las comparaciones.
Ambulatory care sensitive conditions (ACSC) are a set of selected codes of hospital discharge diagnosis that identify hospitalizations considered to be avoidable through the application interventions usually delivered in primary care (PC).
To study the magnitude of avoidable hospitalizations in the region of Murcia (RM) and to assess the usefulness of the “ACSC rate” indicator to test the effectiveness of PC.
The minimum basic data sets (MBDS) for 2002 and 2003 of nine public hospitals in the RM, the 2003 census, and the short-list of ACSC codes were used. The number and percentage of hospital admissions, hospital stays, and deaths from ACSC were determined. Crude and standardized rates were calculated.
Over the 2-year period analyzed, there were 19,108 admissions, 159,180 hospital stays and 1,396 deaths due to ACSC, representing 10.1%, 12.1% and 21.2% of the total number of admissions, stays, and deaths. The crude rate was 75.27% per 10,000 residents. The main cause of ACSC was hypertensive heart disease, followed by heart failure and pneumonia. One of the primary care areas showed a standardized rate ratio of 1.08 (95% confidence interval of 1.03-1.12) compared with the lowest. At the hospital level, the percentage of episodes of ACSC fluctuated between 14.2% and 7.5%. By department the highest percentage of ACSC was found in internal medicine, cardiology and general surgery. Seven diagnosis-related groups accounted for more than 50% of episodes.
There is a wide margin for improvement of the effectiveness of PC in RM, especially in hypertensive heart disease, heart failure, and pneumonia. Before attributing the results to PC, other factors should be ruled out. Differences in the quality of the MBDS may also affect the results.