Racial Disparities in Hospitalizations for Ambulatory Care–Sensitive Conditions

doi:10.1016/j.amepre.2009.12.026

American Journal of Preventive Medicine

Volume 38, Issue 4, April 2010, Pages 381-388

https://doi.org/10.1016/j.amepre.2009.12.026 Get rights and content

Background

Variation in the quality of ambulatory care may be a key factor in explaining disparities in health, and these disparities have large cost implications.

Purpose

This study identified differences in hospitalization rates for elderly African-American and white Marylanders for eight ambulatory care–sensitive conditions (ACSCs). It assessed the relative contribution of race to disparities in preventable hospitalizations after controlling for demographic and socioeconomic factors as well as underlying prevalence. It also estimated the excess cost associated with these disparities.

Methods

Using prevention quality indicator specifications from the Agency for Healthcare and Research Quality applied to 2006 Medicare claims data, eight ACSC hospitalization measures were developed for 569,896 Maryland Medicare beneficiaries. The analysis was conducted in 2008. A Poisson regression model identified race, age, gender, and income as factors associated with differences in ACSC hospitalization rates. Excess costs were estimated from excess hospitalizations of African Americans and the median cost per admission.

Results

African Americans had significantly higher rates of ACSC hospitalizations than whites for five of eight conditions after controlling for demographic, socioeconomic, and geographic factors. Excess costs from disparities in quality ranged from $8 million (heart failure) to $38,000 (urinary tract infection).

Conclusions

Race may be a key predictor of preventable hospitalizations for some ACSCs. Racial disparities in these hospitalizations represent excess costs to Medicare. Because ACSC admissions are potentially preventable with optimal ambulatory care, improving care for minority populations may reduce disparities and lower hospital costs.

Introduction

Disparities in health are thought to result from differences in behavior, SES, environment, and healthcare access and quality.1, 2, 3 Among these factors, the primary focus has been on the last.⁴ Hospitalization for ambulatory care–sensitive conditions (ACSCs)—conditions for which appropriate ambulatory care could prevent hospitalizations—is a frequently used marker for ambulatory care system quality.5, 6 High rates of ACSC-related hospitalizations may indicate problems with healthcare quality and access, and differences in rates among various populations can indicate inequities in quality and access, as well as variation in disease burden and other factors.

Studies have documented differences in rates of ACSC hospitalization (also known as preventable hospitalizations or avoidable hospitalizations) among different demographic and socioeconomic groups. African Americans, Hispanics, and lower-income populations were found to have higher rates of avoidable hospital admissions than their counterparts.7, 8, 9, 10, 11, 12, 13, 14 Studies found that the disparities were particularly pronounced for diabetes, hypertension, congestive heart failure, and asthma. Research also showed8, 11 that ACSC hospitalization rates increased faster for African Americans than for whites in the 1990s and disparities widened.

Studies examining racial and ethnic disparities in ACSC hospitalizations are fewer than expected given the importance of disparities in policy discussions and prior research on differences in quality of care. Among these few studies, there was limited analysis of the factors underlying differences in rates or the costs associated with the disparities in ACSC hospitalizations.13, 14 No studies were identified that examined disparities among the elderly.

Because ACSC hospitalization rates are population-based, including those with or without ACSCs in the denominator of rates, they are driven by a combination of two factors: prevalence of ACSCs in the population and hospitalization rates among those with ACSCs. Thus, disparities in rates are also driven by differences in prevalence of ACSCs, differences in hospitalization rates among those with ACSCs, or both factors. However, most studies examine ACSC hospitalization rates for entire populations without distinguishing between these two factors. Few studies have attempted to account for ACSC prevalence differences when examining disparities in ACSC hospitalization rates.¹³

The present study addresses these gaps in the literature by analyzing preventable hospitalization rates using a regression model to control for the independent effects of demographic, socioeconomic, and geographic factors and adjusting for prevalence of underlying disease. It was hypothesized that this approach will further isolate the role of healthcare system quality in the observed racial disparities in preventable hospitalizations. Moreover, using data from 2006 will provide an updated assessment of these issues compared to other studies that used data from more than 10 years ago.7, 8, 9, 11, 12, 13, 14 During this time, changes in demographics, environment, and quality of healthcare systems have occurred that may have an impact on disparities in preventable hospitalizations. In addition, the present study's consideration of excess costs from disparities can be used as a starting point for discussions of potential savings that may be realized from reducing disparities.

Section snippets

Data Source and Study Population

The present study used data from the 2006 Medicare Denominator file, which includes enrollment information for individual beneficiaries; the 2006 Medicare Provider Analysis and Review file containing inpatient hospital stay records; and 2006 median household income data by ZIP code for Maryland residents aged ≥65 years from the Maryland Census.

The population for analysis included Maryland residents enrolled in fee-for-service (FFS) Part A Medicare for all of 2006 or until death, and who never

Racial Disparities in Ambulatory Care–Sensitive Condition Hospitalization Rates

Among Maryland Medicare FFS beneficiaries, African Americans had significantly higher unadjusted rates of ACSC hospitalizations related to CHF, dehydration, diabetes, adult asthma, and hypertension than whites. (Unadjusted ACSC hospitalization rates are presented later with regression-adjusted rates on Table 3.) Although African Americans had a slightly higher rate for UTI, the difference was not significant. Whites had significantly higher rates for two conditions (COPD and bacterial

Discussion

These results indicate that (1) race is a key predictor of preventable hospitalizations among the elderly for CHF, hypertension, diabetes, and adult asthma; (2) racial disparities in these hospitalization rates are not explained completely by demographic and socioeconomic factors or underlying prevalence; and (3) the excess costs from such disparities are substantial. These results suggest that differences may be due to variation in access to primary care, quality of care, and physician

Conclusion

The 2007 National Healthcare Disparities Report³³ states that disparities in quality and access for minority groups and socioeconomically disadvantaged populations have not improved since the first report in 2003. In addition, although healthcare quality continues to get better, the progress has slowed in recent years.¹⁰ As a result, new strategies to enhance healthcare quality and address disparities are needed to improve the health of the nation.

The current article has presented a method that

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Research articleRacial Disparities in Hospitalizations for Ambulatory Care–Sensitive Conditions

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Data Source and Study Population

Racial Disparities in Ambulatory Care–Sensitive Condition Hospitalization Rates

Discussion

Conclusion

Soc Sci Med

Am J Med

Am J Prev Med

Class—the ignored determinant of the nation's health

N Engl J Med

Fundamental causes of health disparities: a comparative analysis of Canada and the United States

Int Sociol

Understanding health disparities

Unequal treatment: confronting racial and ethnic disparities in healthcare

Guide to prevention quality indicators: hospital admission for ambulatory care sensitive conditions

Access to health care in AmericaIOM

National healthcare disparities report

Trends in avoidable hospitalizations, 1980 to 1998

Health Aff

Recent findings on preventable hospitalizations

Health Aff

Racial and ethnic disparities in potentially preventable hospitalizations, 2003HCUP statistical brief #10

Disparities in trends of hospitalization for potentially preventable chronic conditions among African Americans during the 1990s: implications and benchmarks

Am J Public Health

Racial and ethnic differences in preventable hospitalizations across 10 states

Med Care Res Rev

Race, ethnicity, and hospitalization for six chronic ambulatory care sensitive conditions in the USA

Ethn Health

Research article
Racial Disparities in Hospitalizations for Ambulatory Care–Sensitive Conditions