Family Practice, 2015, Vol. 32, No. 3, 245–246 doi:10.1093/fampra/cmv034
Editorial Preventable hospital admissions: are they?
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]
Reports on the AHRQ website about its PQI, aka ACSC, traced the origins of this list to the early 1990s. Review of those early papers revealed that the original list of conditions was developed by a panel of six physicians, not by any empirical study but by a Delphi process of consensus development. That seemed like a reasonable way to explore a new concept, but I expected it would be followed by studies of actual hospitalizations with these conditions to verify how frequently each condition on the list was indeed preventable, what the most common preventable causes might be and what actions could be taken to prevent admission. As it is likely that many preventable hospitalizations are actually caused by non-medical problems (treatment adherence, financial problems, lack of social support, etc.), I also expected exploration of these cases would have involved talking to patients and families about the factors that they thought contributed to the admission. Although it is certainly possible that my literature searches have missed such studies, I have been unable to find any. In fact, a report from an AHRQ Clinical Expert Review Panel in 2009 said, ‘no studies have reassessed the face validity of these indicators since their original inception, despite advances in clinical medicine and changes in practice patterns’ (3). That expert panel had been convened because it was felt that ‘the PQI are likely to be used in the future for comparative reporting and pay for performance purposes, making validation efforts crucial’. In order to accomplish that, AHRQ recruited a larger panel of 73 clinicians in two panels to repeat the consensus process in a more elaborate way and also recommend potential remedies. However, that panel also did not recommend empirical studies of these events, so there are still none. The current Guide to Prevention Quality Indicators, V3.1, 3/112/07, does not describe any empirical case review data, but it is available at http:// www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V31/ pqi_guide_v31.pdf. Instead, published studies of ‘preventable hospitalizations’ simply accept the 15–16 ACSCs at face value and evaluate their frequency over time, their variation geographically, their relationship to socioeconomic or racial differences and the ability to predict or reduce admissions for these diagnoses (7–9). Not surprisingly, the rates appear to be slowly decreasing, perhaps in part because coding practices would tend to search for conditions that will not lead to punishment. Curiously, Purdey and Huntley’s (5) systematic review found that studies of ‘case management, specialist clinics, care pathways and guidelines, medication reviews, vaccine programmes, and hospital at home do not appear to reduce avoidable admissions’. If these conditions are truly preventable, doesn’t it seem likely that some of those interventions that have been useful for readmission reduction or for a variety of quality improvement initiatives might have been effective?
245
Downloaded from http://fampra.oxfordjournals.org/ at KTH Royal Institute of Technology on November 15, 2015
In a world burdened by record-breaking debt and government budget deficits, the high and rising level of costs for health care are attracting increasing attention and concern, even in developed countries with much lower costs/person than the USA. However, as the world leader in health care costs, pressure to reduce those costs or at least reduce the rate of increase has probably led to more worry, studies, proposals and actions in the USA than elsewhere. As the largest share of those costs are still generated by inpatient (hospital) care, that is increasingly becoming the focus for this attention. According to the California HealthCare Foundation, in the USA in 2012, hospital costs were 32% of the total, not including a sizable share of the physician costs that amounted to another 20% (http://www.chcf.org/chart-cart/presentations/healthcare-costs-101?page=2). Beginning in 2012, Medicare (which pays for most of the care for those >65) has been trying to reduce avoidable hospital readmissions by payment reductions for hospitals with 30-day readmission rates above average for patients with heart attacks, congestive heart failure or pneumonia (1). In 2015, readmissions for chronic lung disease or hip replacement are being added to that program and everyone is anticipating its expansion to other conditions and then to admissions (~10 times as frequent as readmissions) (2). Hospital admissions have already been receiving increased scrutiny from the development and use of prevention quality indicators (PQI) for potentially preventable admissions developed at the Agency for Healthcare Research and Quality (AHRQ) and based on earlier development of ambulatory care sensitive conditions (ACSC) (3). The current list on the AHRQ website includes admissions for diabetes short-term or long-term complications or uncontrol, chronic obstructive lung disease or asthma in older adults, asthma in younger adults, hypertension, heart failure, dehydration, bacterial pneumonia, urinary tract infections, angina without procedure, lower extremity amputations in patients with diabetes and perforated appendix (http://qualityindicators.ahrq.gov/modules/pqi_resources.aspx). The frequency of admissions for these conditions has been used for two decades as a proxy measure of access to care and for identifying care disparities. In fact, virtually all of the increasing frequency of published studies of potentially preventable hospitalizations has relied on measures of the rates of ACSCs, usually assembled from claims data. The same seems to be true for the rest of the world, either by directly using the AHRQ ACSC lists or by developing their own lists (4–6). As both local and national interest in reducing preventable admissions has increased, I became interested in learning about effective causes and preventive strategies. This led me to explore the origins of the ACSCs and what had been published about causes and preventive strategies. But what I learned was very troubling for a problem that was clearly heading for high-priority attention, not only in the USA but around the world.
Family Practice, 2015, Vol. 32, No. 3
246 Hopefully, some more knowledgeable reader will let me know about the important studies I have missed. But unless they exist and are definitive, it seems to be high time to really understand preventable admissions and their prevention and not limit that understanding to some arbitrarily chosen conditions. Thus, this may be an opportunity for primary care clinician–researchers to make an important contribution to a high-priority policy problem, and this journal would enjoy receiving such manuscripts.
Declaration
Leif I Solberg* HealthPartners Institute for Education and Research, Minneapolis, MN, USA. *Correspondence to Leif I Solberg, HealthPartners Institute for Education and Research, PO Box 1524, MS #23301A, Minneapolis, MN 55440, USA; E-mail: leif.i.solberg@ healthpartners.com
1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med 2013; 368: 1175–7. 2. Trudnak T, Kelley D, Zerzan J et al. Medicaid admissions and readmissions: understanding the prevalence, payment, and most common diagnoses. Health Aff (Millwood) 2014; 33: 1337–44. 3. Davies SM, McDonald KM, Schmidt E et al. Expanding Use of the Prevention Quality Indicators: Report of Clinical Expert Review Panel. Rockville, MD: AHRQ, 2009. 4. Purdy S, Griffin T, Salisbury C, Sharp D. Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Public Health 2009; 123: 169–73. 5. Purdey S, Huntley A. Predicting and preventing avoidable hospital admissions: a review. J R Coll Physicians Edinb 2013; 43: 340–4. 6. Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy 2000; 5: 222–30. 7. Torio CM, Elixhauser A, Andrews RM. Trends in Potentially Preventable Admissions Among Adults and Children, 2005–2010. Rockville, MD: AHRQ, 2013. 8. Russo CA, Andrews RM, Coffey RM. Racial and Ethnic Disparities in Potentially Preventable Hospitalizations, 2003. Rockville, MD: AHRQ, 2006. 9. Torio CM, Andrews RM. Geographic Variation in Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2005–2011. Rockville, MD: AHRQ, 2014.
Downloaded from http://fampra.oxfordjournals.org/ at KTH Royal Institute of Technology on November 15, 2015
Funding: This publication was made possible by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Ethical approval: none. Conflict of interest: none.
References
Editorial Preventable hospital admissions: are they?
© The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected]
Reports on the AHRQ website about its PQI, aka ACSC, traced the origins of this list to the early 1990s. Review of those early papers revealed that the original list of conditions was developed by a panel of six physicians, not by any empirical study but by a Delphi process of consensus development. That seemed like a reasonable way to explore a new concept, but I expected it would be followed by studies of actual hospitalizations with these conditions to verify how frequently each condition on the list was indeed preventable, what the most common preventable causes might be and what actions could be taken to prevent admission. As it is likely that many preventable hospitalizations are actually caused by non-medical problems (treatment adherence, financial problems, lack of social support, etc.), I also expected exploration of these cases would have involved talking to patients and families about the factors that they thought contributed to the admission. Although it is certainly possible that my literature searches have missed such studies, I have been unable to find any. In fact, a report from an AHRQ Clinical Expert Review Panel in 2009 said, ‘no studies have reassessed the face validity of these indicators since their original inception, despite advances in clinical medicine and changes in practice patterns’ (3). That expert panel had been convened because it was felt that ‘the PQI are likely to be used in the future for comparative reporting and pay for performance purposes, making validation efforts crucial’. In order to accomplish that, AHRQ recruited a larger panel of 73 clinicians in two panels to repeat the consensus process in a more elaborate way and also recommend potential remedies. However, that panel also did not recommend empirical studies of these events, so there are still none. The current Guide to Prevention Quality Indicators, V3.1, 3/112/07, does not describe any empirical case review data, but it is available at http:// www.qualityindicators.ahrq.gov/Downloads/Modules/PQI/V31/ pqi_guide_v31.pdf. Instead, published studies of ‘preventable hospitalizations’ simply accept the 15–16 ACSCs at face value and evaluate their frequency over time, their variation geographically, their relationship to socioeconomic or racial differences and the ability to predict or reduce admissions for these diagnoses (7–9). Not surprisingly, the rates appear to be slowly decreasing, perhaps in part because coding practices would tend to search for conditions that will not lead to punishment. Curiously, Purdey and Huntley’s (5) systematic review found that studies of ‘case management, specialist clinics, care pathways and guidelines, medication reviews, vaccine programmes, and hospital at home do not appear to reduce avoidable admissions’. If these conditions are truly preventable, doesn’t it seem likely that some of those interventions that have been useful for readmission reduction or for a variety of quality improvement initiatives might have been effective?
245
Downloaded from http://fampra.oxfordjournals.org/ at KTH Royal Institute of Technology on November 15, 2015
In a world burdened by record-breaking debt and government budget deficits, the high and rising level of costs for health care are attracting increasing attention and concern, even in developed countries with much lower costs/person than the USA. However, as the world leader in health care costs, pressure to reduce those costs or at least reduce the rate of increase has probably led to more worry, studies, proposals and actions in the USA than elsewhere. As the largest share of those costs are still generated by inpatient (hospital) care, that is increasingly becoming the focus for this attention. According to the California HealthCare Foundation, in the USA in 2012, hospital costs were 32% of the total, not including a sizable share of the physician costs that amounted to another 20% (http://www.chcf.org/chart-cart/presentations/healthcare-costs-101?page=2). Beginning in 2012, Medicare (which pays for most of the care for those >65) has been trying to reduce avoidable hospital readmissions by payment reductions for hospitals with 30-day readmission rates above average for patients with heart attacks, congestive heart failure or pneumonia (1). In 2015, readmissions for chronic lung disease or hip replacement are being added to that program and everyone is anticipating its expansion to other conditions and then to admissions (~10 times as frequent as readmissions) (2). Hospital admissions have already been receiving increased scrutiny from the development and use of prevention quality indicators (PQI) for potentially preventable admissions developed at the Agency for Healthcare Research and Quality (AHRQ) and based on earlier development of ambulatory care sensitive conditions (ACSC) (3). The current list on the AHRQ website includes admissions for diabetes short-term or long-term complications or uncontrol, chronic obstructive lung disease or asthma in older adults, asthma in younger adults, hypertension, heart failure, dehydration, bacterial pneumonia, urinary tract infections, angina without procedure, lower extremity amputations in patients with diabetes and perforated appendix (http://qualityindicators.ahrq.gov/modules/pqi_resources.aspx). The frequency of admissions for these conditions has been used for two decades as a proxy measure of access to care and for identifying care disparities. In fact, virtually all of the increasing frequency of published studies of potentially preventable hospitalizations has relied on measures of the rates of ACSCs, usually assembled from claims data. The same seems to be true for the rest of the world, either by directly using the AHRQ ACSC lists or by developing their own lists (4–6). As both local and national interest in reducing preventable admissions has increased, I became interested in learning about effective causes and preventive strategies. This led me to explore the origins of the ACSCs and what had been published about causes and preventive strategies. But what I learned was very troubling for a problem that was clearly heading for high-priority attention, not only in the USA but around the world.
Family Practice, 2015, Vol. 32, No. 3
246 Hopefully, some more knowledgeable reader will let me know about the important studies I have missed. But unless they exist and are definitive, it seems to be high time to really understand preventable admissions and their prevention and not limit that understanding to some arbitrarily chosen conditions. Thus, this may be an opportunity for primary care clinician–researchers to make an important contribution to a high-priority policy problem, and this journal would enjoy receiving such manuscripts.
Declaration
Leif I Solberg* HealthPartners Institute for Education and Research, Minneapolis, MN, USA. *Correspondence to Leif I Solberg, HealthPartners Institute for Education and Research, PO Box 1524, MS #23301A, Minneapolis, MN 55440, USA; E-mail: leif.i.solberg@ healthpartners.com
1. Joynt KE, Jha AK. A path forward on Medicare readmissions. N Engl J Med 2013; 368: 1175–7. 2. Trudnak T, Kelley D, Zerzan J et al. Medicaid admissions and readmissions: understanding the prevalence, payment, and most common diagnoses. Health Aff (Millwood) 2014; 33: 1337–44. 3. Davies SM, McDonald KM, Schmidt E et al. Expanding Use of the Prevention Quality Indicators: Report of Clinical Expert Review Panel. Rockville, MD: AHRQ, 2009. 4. Purdy S, Griffin T, Salisbury C, Sharp D. Ambulatory care sensitive conditions: terminology and disease coding need to be more specific to aid policy makers and clinicians. Public Health 2009; 123: 169–73. 5. Purdey S, Huntley A. Predicting and preventing avoidable hospital admissions: a review. J R Coll Physicians Edinb 2013; 43: 340–4. 6. Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy 2000; 5: 222–30. 7. Torio CM, Elixhauser A, Andrews RM. Trends in Potentially Preventable Admissions Among Adults and Children, 2005–2010. Rockville, MD: AHRQ, 2013. 8. Russo CA, Andrews RM, Coffey RM. Racial and Ethnic Disparities in Potentially Preventable Hospitalizations, 2003. Rockville, MD: AHRQ, 2006. 9. Torio CM, Andrews RM. Geographic Variation in Potentially Preventable Hospitalizations for Acute and Chronic Conditions, 2005–2011. Rockville, MD: AHRQ, 2014.
Downloaded from http://fampra.oxfordjournals.org/ at KTH Royal Institute of Technology on November 15, 2015
Funding: This publication was made possible by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Ethical approval: none. Conflict of interest: none.
References
