Differences in the prevalence of hospitalizations and utilization of emergency outpatient services for ambulatory care sensitive conditions between asylum-seeking children and children of the general population: a cross-sectional medical records study (2015)

Access to health care for migrants seeking international protection in Germany is regulated by the Asylum Seekers’ Benefits Act ("Asylbewerberleistungsgesetz"). This law grants asylum seekers basic health care services. Benefits allocated for medical care cover necessary medical or dental treatment of acute illness and pain, including the provision of medication and bandages and necessary measures for convalescence, recovery or alleviation of disease or necessary services addressing consequences of illnesses [1]. Vaccination and “necessary preventive medical check-ups” are also to be provided. In addition, pregnant women and women who have recently given birth are entitled to “medical and nursing help and support” including midwife assistance. The respective federal state’s administrative regional council ("Regierungspräsidium") covers the costs for health care for asylum seekers residing in reception centers. Asylum seekers undergo a mandatory health examination [2] focused on infectious diseases in reception centers, and reside there for up to 6 months until they are transferred to cities or communities based on specific dispersal policies. After transfer of asylum seekers to collective accommodation centers or decentralized accommodation, the social welfare office of the responsible district bears the incurred costs.

Health care in German reception centers is often provided on an irregular basis [3]. Due to reception centers often being located in remote geographical areas with insufficient local transport to health care providers, the availability of accessible health care services is also limited. In addition, asylum seekers may lack sufficient knowledge on their entitlements to health care, the underlying regulations and the structure of medical care (primary, secondary and tertiary care) due to lack of communication, language barriers or other reasons and therefore not make use of said entitlements [4]. As a result, these barriers can lead to delayed care, which results in costly treatment [5]. In the European Union (EU) / European Economic Area (EEA), Germany stands out as one of the countries with the most restrictive health care policy for migrant children [6]. In the last decade, several models of health care provision to asylum seekers in reception centers have emerged in Germany, aiming at overcoming the aforementioned barriers [7]. There is, however, a lack of approaches to objectively compare different models with respect to their performance. Comparisons are also challenged by a relative lack of individual-level data on health and health care utilization among asylum seekers. This information is not routinely collected in Germany across regions and health care sectors [8, 9], turning the effects of barriers on access to health care invisible.

On an international level ambulatory care sensitive (ACS) hospitalizations are increasingly used as an indicator for the availability and quality of ambulatory care [10]. The concept of ACS hospitalizations is based on the assumption that a deficit of timely and effective outpatient care can lead to avoidable hospital admissions and potentially preventable hospitalizations. ACS conditions have been defined [11] as those conditions for which “the provision of timely and effective outpatient care can help to reduce the risks of hospitalization by either preventing the onset of an illness or condition, controlling an acute episodic illness or condition, or managing a chronic disease or condition” [1].

As a proof of concept, we aimed to assess the differences between asylum-seeking children and children of the general population in a German city with respect to (i) the prevalence of ACS hospitalizations, and (ii) the utilization of emergency outpatient services for ACS conditions.

Ambulatory care sensitive (ACS) hospitalizations have increasingly been used as an indicator for the availability and quality of ambulatory care on an international level [10]. As a proof of concept, our objective was to assess the differences between asylum-seeking children and children of the general population in a German city with respect to (i) the prevalence of ACS hospitalizations, and (ii) the utilization of emergency outpatient services for ACS conditions. Our main finding is that asylum-seeking minors do have significantly higher odds of hospitalizations for ACS conditions and of utilization of emergency outpatient services for ACS conditions compared to the general population. The observed associations could not be explained by differences in age, sex or different periods of admission throughout the year.

The percentage of asylum-seeking children being hospitalized for ACS conditions was 7% higher than that of the control group, in emergency services use it was nearly 22% higher. This high use of especially emergency outpatient services for ACS conditions among the asylum-seeking population indicates that the preceding entities in ambulatory care were weak, overloaded or insufficient. However, residual confounding by differences in children’s socio-economic status and parents’ health seeking behavior cannot be ruled out (see below).

Nearly 50% of the ACS hospitalizations among asylum-seeking children were attributable to their exposure (Afe), but the hospitalizations in this group contributed only to slightly more than 1% to the ACS hospitalizations in the whole population, i.e. the total admissions (PAF). While avoiding ACS hospitalizations in the asylum-seeking population is an important goal, addressing ACS hospitalizations in children of the general population would have an even higher public health impact. In outpatient care, nearly 80% of emergency service use for ACS conditions among asylum-seeking children was attributable to their exposure, and about 5% of all emergency service utilizations for ACS conditions could have been averted in absence of the exposure (everything else held constant).

Rates of preventable hospitalization have been used as quality indicators of healthcare provided to populations, as access indicators of primary care and as indicators of outpatient care related to primary care capacity [22]. The main strength of our study was building a useful approach in explicitly measuring deficits in primary care among asylum-seeking populations. The quality indicator ACS hospitalizations allowed quantification of disparities in health services.

The main limitation of our study concerns measurement of influences on ACS hospitalizations outside of the control of the ambulatory care sector, which are often difficult to adjust for. The health of a child can be influenced by many factors beyond the control of a physician, beginning with parental decisions to socioeconomic factors, patient demographics, environment and many more [20]. Many of these factors are difficult to measure and adjust for due to lack of according data. Studies have shown that not only quality of primary care is of importance but also that the characteristics of population and the supply of secondary care resources play a considerable role [1, 23]. Having experienced forced displacement, stress and trauma prior to entering the country of resettlement, forced migrants are more likely to present a different burden of disease and other spectrum of illnesses than the host countries’ population. A particular vulnerability and risk is given regarding specific health conditions, such as infectious, mental and non-communicable chronic diseases [24‐26]. Research on the impact of socioeconomic status on hospital use in New York [1] discovered that for all ACS conditions combined, low income areas had rates four times higher, with nearly 70% of the variation explained by area income. Trachtenberg et al. [27] came to a similar conclusion when examining the relationship between respiratory hospitalizations and socioeconomic status and inequities in ambulatory care: the association of socioeconomic status with potentially preventable hospitalizations showed that the odds of being hospitalized in the lowest income group were approximately 3 times higher than the highest income group. This does show that especially socioeconomic status is a variable that does very much have to be taken into account when measuring and using the indicator ACS hospitalizations. Even with adequate primary care, there exists the possibility that a child may be hospitalized for preventable or ACS conditions either because of extraneous factors such as the above mentioned or however an uncontrollable, fulminant exacerbation of their illness [20]. Although ACS conditions have been used in a multitude of analyses to examine avoidability of hospitalizations, they therefore remain an imperfect measure of directly measuring access to primary care [20]. While we had data on children receiving social welfare transfers, it was not possible to disaggregate by residence status in order to determine whether or not these children were asylum seekers. Better identification of migrants in the German health information system is needed [28] to disentangle the impact of migration status separately from that of socioeconomic status.

The role of health seeking behavior and its influence on health care utilization is a point of discussion in this context. As health care systems worldwide differ in many ways, asylum seekers may lack sufficient knowledge and information of and on the structures of our health care system, consequently make more use of emergency outpatient services [4, 29, 30]. Both the different perception and understanding of illnesses and different expectation of treatment could lead to further challenges in the relationship between a medical practitioner and his patient and thus have an influence on the outcome of the treatment. Interviews with health care professionals in 16 European countries showed that expressions of aetiology, symptoms, and pain can make it difficult for an accurate diagnosis to be made, especially when understanding of these concepts greatly differs between the patient and practitioner [4]. This presents the question, if results uncover barriers in access to ambulatory care, fundamental weaknesses in primary care or rather show cultural differences regarding use of health services and medical knowledge. Furthermore, access to appropriate language interpretation is paramount for the appropriate management of asylum seekers’ health [31‐33], both in terms of explaining symptoms and in following medical recommendations. In our case, bilingual health care staff, residents of the Patrick Henry Village and lay volunteers provided language interpretation. Shortages of interpreters and communication problems were listed as the largest problem in all administrative meetings of the on-site clinic [7].

Coding behavior in hospitals is a factor that also has to be taken into account. Although the source of data is reliable, the underlying coding behavior in hospitals influences the quality of the data significantly [34]. Overall, however, a largely consistent and standardized coding is to be assumed, due to the German Hospital Reimbursement Act ("Krankenhausentgeltgesetz") [34].

Missing identification of primary diagnoses among the outpatient care data could also lead to a distortion of the results, as the diagnosis, which may have ultimately lead to use of emergency care, would trump further ACS conditions within the same hospital case.

In the process of a systematic review on potentially avoidable and ACS hospitalizations among forced migrants [35], only few empirical studies have been found on ACS conditions and hospitalizations among asylum seekers and the broader population group of forced migrants. Preliminary results indicate that the indicator has not been widely used to display differences and disparities in access to ambulatory care among forced migrants and the domestic population.

By conducting this study and demonstrating an association of the indicators ACS hospitalizations and ACS conditions with children’s residence status we aimed to establish a base line for further research. This approach could help to compare the strength of primary care provision in different locations, and allow an objective analysis of regional health system performance from a primary care perspective.

Our objective was to assess the differences between asylum-seeking children and children of the general population in a German city with respect to the prevalence of ambulatory care sensitive (ACS) hospitalizations and the utilization of emergency outpatient services for ACS conditions. We found that asylum-seeking children had significantly higher odds of hospitalization and of utilization of emergency outpatient services for ACS conditions. The use of emergency outpatient services for ACS conditions among the asylum-seeking population was nearly five times the use of the control group. In inpatient care, the odds for hospitalization of asylum-seeking children in comparison to children of the general population for ACS conditions were significantly higher (around 80%).

Using the concept of ACS conditions allowed measuring the strength of primary care provided to this local asylum-seeking population. We hope to have established a base line for further research, as this approach could help to compare the strength of primary care provision in different locations, quantify observed deficits and allow an objective analysis of regional health system performance from a primary care perspective.