Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

Abstract

BackgroundA relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.MethodsFrom the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.ResultsOverall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.ConclusionsThe socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.

Desigualdades intraurbanas de taxas de internações por condições sensíveis à atenção primária na região central do Brasil

“…Kidney and urinary tract infections were the third most common cause of admissions. These findings are consistent with the findings described in the literature, which show that rates of admissions for ACSCs are higher among this age group 5,7,[49][50][51][52] . The most prevalent conditions among the 60 years and over age group were circulatory system diseases, the most common of which were heart failure, angina and cerebrovascular diseases.…”

“…Studies have reported varying rates of admissions for ACSCs across different countries. In Italy, Agabiti et al 7 observed rates of 26.1 per 10,000 population, while in Switzerland, Eggli et al 8 found rates of 10 per 1,000 population among patients with private health insurance. The most common causes of ACSC admissions described in the national and international literature are gastroenteritis, kidney and urinary tract infections, heart failure, angina, asthma, and diabetes mellitus [9][10][11][12][13][14][15] .…”

Social determinants of intra-urban differentials of admissions by respiratory diseases in Salvador (BA), Brazil

“…Low income, however, remained associated even after multivariate analysis. A more recent study 21 showed an inverse gradient between income level and hospitalization rates for asthma and COPD. Other authors have also demonstrated the adverse effect of the worst income and education rates on respiratory diseases 5,22,23 , but they do not correlate these determinants with the outcome of hospitalization.…”

Continuity of Care and Avoidable Hospitalizations for Chronic Obstructive Pulmonary Disease (COPD)

“…Moreover, both these definitions identified COPD as an ambulatory care-sensitive condition. Previous studies showed that personal socioeconomic status, 23,29,30 health status, 24,31 and health care access 24,30,32 are associated with avoidable hospitalizations. To the best of our knowledge, however, few studies examined the relationship between COC and avoidable hospitalizations; the majority of these studies included several diseases, [33][34][35] but only 1 study focused on diabetes.…”