Elsevier

Social Science & Medicine

Volume 57, Issue 8, October 2003, Pages 1429-1441
Social Science & Medicine

Hospital utilization for ambulatory care sensitive conditions: health outcome disparities associated with race and ethnicity

https://doi.org/10.1016/S0277-9536(02)00539-7Get rights and content

Abstract

Our study examines associations between race and ethnicity and hospitalization for ambulatory care sensitive (ACS) conditions for working age adults, and for individuals age 65 or older. We use ACS hospitalization as an outcome indicator to evaluate access to primary care. The prevalence of ACS conditions in the population, including those not hospitalized, and the occurrence of ACS and non-ACS hospitalization, are estimated using nationally representative data from the 1997 US Medical Expenditure Panel Survey. We calculate population-based relative rates of ACS hospitalization using the 1997 Nationwide Inpatient Sample, a large sample of United States’ community hospitals, and the US Census. We investigate the sensitivity of these relative rates to the inclusion of conditions for which hospitalization varies notably across areas, and adjust the rates for both underlying hospitalization patterns for non-ACS conditions, and for disease prevalence in the population groups studied. The analyses consistently show that African Americans and Hispanics have significantly higher rates of ACS hospitalization than non-Hispanic whites. This result applies to women and men, and both age groups studied. These higher rates persist after adjusting for disease prevalence and non-ACS admission rates, and for the inclusion of high variation conditions.

Introduction

Considerable evidence has shown wide disparities in the availability and quality of medical services among groups defined by race and ethnicity. Studies have consistently shown that African Americans and Hispanics use less medical care than non-Hispanic white Americans (American College of Physicians, 2000; Mayberry, Mili, & Ofili, 2000). They see physicians less often, have fewer diagnostic tests and procedures, less disease screening and preventive care, and fewer referrals to specialists. Some of these disparities are attributable to socioeconomic status (Blackwell, Hayward & Crimmins, 2001; Hayward, Miles, Crimmins, & Yang, 2000). But disparities persist when socioeconomic status is controlled (Gornick, 2000; Shi, 2000; Weinick, Zuvekas, & Cohen, 2000; Williams & Collins, 1999; Williams & Rucker, 2000). Most studies of access to care by vulnerable groups focus on standard process measures, such as having insurance or a usual source of care. These studies do not address health outcomes—which are precisely the objective of efforts to reduce access disparities. Outcome measures can provide objective information about the quality of primary health care as well as its accessibility. These measures can also allow policy makers to better judge the trade-offs that inevitably accompany policy decisions.

Hospitalization for ambulatory care sensitive conditions (ACSH) is an outcome indicator used to evaluate access to primary care (Billings, Anderson, & Newman, 1996; Bindman et al., 1995; Millman, 1993). A relatively small number of studies have investigated associations between race and ethnicity and ACSH, which is sometimes called potentially preventable hospitalization. Our study adds to this body of research by comparing both the prevalence of ambulatory care sensitive (ACS) conditions and rates of ACSH for African Americans and Hispanics to those of non-Hispanic whites. We investigate the sensitivity of these comparisons to the inclusion of conditions for which hospitalization varies notably across areas.

Section snippets

ACSH and recent empirical research

Billings (1990), with an advisory panel of experts on primary care access, developed the ACS category. In 1993, the United States’ Institute of Medicine (IOM) recommended ACSH as an outcome indicator of primary care access (Millman, 1993). The rationale underlying the ACSH indicator is that outpatient care of ACS conditions can reduce the risk of hospitalization (Bindman et al., 1995; Millman, 1993; Weissman, Gatsonis, & Epstein, 1992). It can do so in one of three ways. First, it can prevent

Data overview

Hospital discharge data representing 14 states are from the 1997 Nationwide Inpatient Sample (NIS), a 20% sample of United States community hospitals from the Healthcare Cost and Utilization Project 1988–1997 (HCUP). Population estimates are from the Area Resource File. We estimated the prevalence of ACS conditions, and the occurrence of hospitalizations for these conditions, using the 1997 Medical Expenditure Panel Survey (MEPS). The MEPS provides a nationally representative sample of the

Results

Our primary analysis focuses on relative rates calculated using the NIS. To provide a context for these results, however, we first present the MEPS analysis of ACS disease prevalence and hospitalization. Prevalence rates are shown in Table 3, together with rates for both ACSH and non-ACSH.5

Discussion

Our results consistently show that African Americans and Hispanics are at substantially higher risk of ACSH than non-Hispanic whites. This finding was true for both working age adults and older individuals. These differences persisted after adjusting for the occurrence of non-ACSH, and for the prevalence of ACS conditions in these populations. The analyses also examined the sensitivity of these findings to the inclusion of conditions for which admission rates vary greatly across areas. In most

Acknowledgements

We thank Deborah Freund, Ph.D., Eugene Nelson, D.Sc., M.P.H., Manon Spitzer Ruben, M.A., Douglas Wolf, Ph.D., and three anonymous reviewers for useful comments that contributed to this research.

References (54)

  • J. Billings et al.

    Recent findings on preventable hospitalizations

    Health Affairs

    (1996)
  • Billings, J., & Hasselblad, V. (1989). A preliminary study: Use of small area analysis to assess the performance of the...
  • J. Billings et al.

    DataWatchImpact of socioeconomic status on hospital resource use in New York city

    Health Affairs

    (1993)
  • A.B. Bindman et al.

    Preventable hospitalizations and access to health care

    Journal of the American Medical Association

    (1995)
  • J. Blustein et al.

    Preventable hospitalizations and socioeconomic status

    Health Affairs

    (1998)
  • Bound, J., Brown, C., & Mathiowetz, N. (2000). Measurement in survey data. In: J. Heckman & E. Leamer (Eds.), Handbook...
  • Caralis, P.V. (1990). Hypertension in the Hispanic-American population. American Journal of Medicine, 88(3B),...
  • P.H. Chang et al.

    Language barriers to health careAn overview

    Journal of Health Care for the Poor and Underserved

    (1998)
  • J. Chen et al.

    Racial differences in the use of cardiac catheterization after acute myocardial infarction

    New England Journal of Medicine

    (2001)
  • D.O. Clark et al.

    Race, age, chronic disease, and disability

  • B.G. Cox et al.

    A comparison of household and provider reports of medical conditions

    Journal of the American Statistical Association

    (1987)
  • S.D. Culler et al.

    Factors related to potentially preventable hospitalizations among the elderly

    Medical Care

    (1998)
  • Daughety, V.S. (1979). Illness conditions. In: R. Andersen, J. Kasper, M.R. Frankel, & associates (Eds.), Total survey...
  • Duffy, S.Q., & Sommers, J.P. (1999). Technical supplement 11: Calculating variances using data from the HCUP Nationwide...
  • K. Fiscella et al.

    Inequality in qualityAddressing socioeconomic, racial, and ethnic disparities in health care

    Journal of the American Medical Association

    (2000)
  • S. Foote et al.

    Disability profile and health care costs of Medicare beneficiaries under age 65

    Health Affairs

    (2001)
  • L.V. Franse et al.

    Type 2 diabetes in older well-functioning peopleWho is undiagnosed? Data from the health, aging, and body composition study

    Diabetes Care

    (2001)
  • Cited by (118)

    • Racial disparities in provider-patient communication of incidental medical findings

      2021, Social Science and Medicine
      Citation Excerpt :

      For example, evidence indicating “differential diagnosis and treatment for a wide range of diseases and disorders” across racial groups serves as striking evidence that healthcare providers routinely, “… employ racially-motivated thinking” when treating patients of color (Hoberman, 2007, 507). Discriminatory treatment of patients of color within healthcare contexts has been documented in multiple studies, demonstrating that patients of color receive lower-quality and less rigorous care across a variety of conditions (King and Redwood, 2016; Laditka et al., 2003; Phelan and Link, 2015; Schpero et al., 2017; Van Ryn and Burke, 2000). Patients of color are more likely to receive inadequate treatment recommendations for breast cancer and cardiovascular diseases (Beyer et al., 2019; Williams and Wyatt, 2015), and Ashton et al. (2003) and Mayberry et al. (2000) have shown that Black patients often receive less clinical attention and fewer diagnostic tests than White patients, net of other health factors.

    • Impact of Brazil's More Doctors Program on hospitalizations for primary care sensitive cardiovascular conditions

      2020, SSM - Population Health
      Citation Excerpt :

      An extensive literature shows that timely and appropriate provision of primary care may lead to sizeable reductions in hospitalizations for a range of chronic and acute health conditions (Ansari, 2007; Billings et al. 1993). Previous studies indicate that high rates of primary care sensitive hospitalizations may signal challenges in access to and quality of primary care, inadequate distribution of resources for health, or a mismatch between the availability of services and the needs of the population (AHRQ 2001; Ansari, 2007; Caminal et al. 2004; Laditka et al. 2003; Rosano et al. 2012). Yet, available evidence on the relationship between increased investment in primary care and the use of hospital services is mixed (Gibson et al. 2013; Rosano et al. 2012).

    View all citing articles on Scopus
    View full text