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.

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