Primary Care Providers Deem Significant Share of Hospitalizations Avoidable

Primary care physicians rate more than 40 percent of hospitalizations resulting from ambulatory care-sensitive conditions (ACSCs) as avoidable with effective preventive care and disease management, according to new research published in the July/August 2013 issue of the Annals of Family Medicine.

For their “Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care-Sensitive Conditions” study, Tobias Freund, MD, from the general practice and health services research department of University Hospital Heidelberg in Germany, and UK researchers from the University of Warwick and the University of Manchester interviewed 12 primary care physicians from 10 German clinics, exploring 104 hospitalizations for 81 patients with ACSCs identified through insurance claims data for hospital admissions.

During the interviews, the physicians rated each hospitalization for ACSCs based on whether it could have been avoided and then suggested the causes that resulted in each hospitalization. Examining the data from those interviews, the investigators determined that the physicians rated 43 of the 104 ACSC hospitalizations — or 41 percent of the cases — to be potentially avoidable.

Explanations and causes of those avoidable ambulatory care-sensitive hospitalizations were identified at the system, physician, medical, patient, and social levels, and on average, the physicians attributed 2.5 causes to each hospitalization. Medical- and patient-related causes — such as major somatic or psychiatric comorbidity and patient fearfulness — were the most frequent pairing, though other factors included after-hours absence of the treating physician, inadequate patient monitoring, lack of social support, treatment errors, and medication nonadherence. (Table) Among the 61 ACSC hospitalizations rated as unavoidable, medical emergencies and comorbidities were frequently cited as the causes.

Although their research mainly calls attention to the need for “a number of interventions … to take up the challenge of potentially avoidable hospitalizations in primary care practice”, the authors also noted that the results “highlight the importance of a more differentiated view of hospitalizations for ACSC as an indicator for the quality of primary care by combining data from insurance claims and comprehensive case audits with treating physicians who are aware of the complex causality of potentially avoidable hospitalization.”

“From the perspective of the physicians in our study — and based on avoidability ratings — some causes of hospitalizations for ACSC are under the direct control of primary care more than others,” the authors concluded. Thus, the researchers suggested several implications for primary care practice teams, which included high-risk patient recognition; regular medication review and symptom monitoring; self-management training for patients and caregivers; and health technology systems implementation.