Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states (original) (raw)

Abstract

Background: Federally qualified community health centers (CHCs) and rural health clinics (RHCs) are intended to provide access to care for vulnerable populations. While some research has explored the effects of CHCs on population health, little information exists regarding RHC effects. We sought to clarify the contribution that CHCs and RHCs may make to the accessibility of primary health care, as measured by county-level rates of hospitalization for ambulatory care sensitive (ACS) conditions. Methods: We conducted an ecologic analysis of the relationship between facility presence and county-level hospitalization rates, using 2002 discharge data from eight states within the US (579 counties). Counties were categorized by facility availability: CHC(s) only, RHC(s) only, both (CHC and RHC), and neither. US Agency for Healthcare Research and Quality definitions were used to identify ACS diagnoses. Discharge rates were based on the individual's county of residence and were obtained by dividing ACS hospitalizations by the relevant county population. We calculated ACS rates separately for children, working age adults, and older individuals, and for uninsured children and working age adults. To ensure stable rates, we excluded counties having fewer than 1,000 residents in the child or working age adult categories, or 500 residents among those 65 and older. Multivariate Poisson analysis was used to calculate adjusted rate ratios. Results: Among working age adults, rate ratio (RR) comparing ACS hospitalization rates for CHConly counties to those of counties with neither facility was 0.86 (95% Confidence Interval, CI, 0.78-0.95). Among older adults, the rate ratio for CHC-only counties compared to counties with neither facility was 0.84 (CI 0.81-0.87); for counties with both CHC and RHC present, the RR was 0.88 (CI 0.84-0.92). No CHC/RHC effects were found for children. No effects were found on estimated hospitalization rates among uninsured populations. Conclusion: Our results suggest that CHCs and RHCs may play a useful role in providing access to primary health care. Their presence in a county may help to limit the county's rate of hospitalization for ACS diagnoses, particularly among older people.

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References (45)

  1. Economic Research Service, US Department of Agriculture: Rural Poverty at a Glance. Rural Development Research Report Number 100 2004 [http://www.ers.usda.gov/publications/rdrr100/ rdrr100_lowres.pdf].
  2. Vlahov D, Galea S: Urbanization, urbanicity, and health. J Urban Health 2002, 79(4 Suppl 1):S1-S12.
  3. Bureau of Primary Health Care: Uniform Data System, 2006 National Reports, Table 3b. [http://bphc.hrsa.gov/uds/2006data/ National/NationalTable3BUniversal.htm].
  4. Bureau of Primary Health Care: Uniform Data System, 2006 National Reports, Table 4. [http://bphc.hrsa.gov/uds/2006data/ National/NationalTable4Universal.htm].
  5. Bureau of Primary Health Care: BPHC Policy Information Notice: 98-23. 1998 [http://bphc.hrsa.gov/policy/pin9823/ default.htm].
  6. Centers for Medicare and Medicaid Services: Rural Health Clinic Fact Sheet. 2007 [http://www.cms.hhs.gov/MLNProducts/down loads/rhcfactsheet.pdf].
  7. Government Accountability Office Health Professional Shortage Areas: Problems Remain with Primary Care Shortage Area Designation System. Washington, DC. GAO-07-84 2006.
  8. General Accounting Office: Health Centers and Rural Clinics. Payments Likely to be Constrained Under Medicaid's New System. Washington, DC GAO-01-577 2001.
  9. Billings J, Hasselblad V: A Preliminary Study: Use of Small Area Analysis to Assess the Performance of the Outpatient Deliv- ery System of New York City. Report prepared for the Health Sys- tems Agency of New York City. New York, NY 1989.
  10. Billings J, Teicholz N: Data Watch: Uninsured patients in Dis- trict of Columbia hospitals. Health Affairs 1990, 9:158-165.
  11. Billings J: Consideration of the use of small area analysis as a tool to evaluate barriers to access. In Health Resources and Serv- ices Administration, Consensus on Small Area Analysis. DHHS Pub. No. HRSA-PE 91-1[A] Washington, D.C.: U.S. Department of Health and Human Services; 1990.
  12. Billings J, Zeitel L, Lukomnik J, Carey TS, Blank AE, Newman L: Impact of Socioeconomic Status On Hospital Resource Use in New York City. Health Affairs 1993, 12:162-73.
  13. Billings J, Anderson GM, Newman LS: Recent findings on prevent- able hospitalizations. Health Affairs 1996, 15:239-249.
  14. Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, Billings J, Stewart A: Preventable Hospitalizations And Access To Health Care. Journal of the American Medical Association 1995, 274:305-11.
  15. Weissman JS, Gatsonis C, Epstein AM: Rates of Avoidable Hospi- talization By Insurance Status in Massachusetts and Mary- land. Journal of the American Medical Association 1992, 268:2388-94.
  16. Pappas G, Hadden WC, Kozak LJ, Fisher GF: Potentially Avoidable Hospitalizations: Inequalities in Rates Between US Socioe- conomic Groups. American Journal of Public Health 1997, 87:811-6.
  17. Laditka JN: Physician Supply, Physician Diversity, and Out- comes of Primary Health Care for Older Persons in the United States. Health and Place 2004, 10:231-44.
  18. Ansari Z, Laditka JN, Laditka SB: Access to Health Care And Hos- pitalization For Ambulatory Care Sensitive Conditions. Med- ical Care Research and Review 2006, 63:719-41.
  19. Silver MP, Babitz ME, Magill MK: Ambulatory Care Sensitive Hos- pitalization Rates In The Aged Medicare Population In Utah, 1990 To 1994: A Rural-Urban Comparison. Journal of Rural Health 1997, 13:285-94.
  20. Culler SD, Parchman ML, Przybylski M: Factors Related To Poten- tially Preventable Hospitalizations Among The Elderly. Med- ical Care 1998, 36:804-17.
  21. Laditka JN, Laditka SB, Probst JC: Hospitalization for Ambulatory Care Sensitive Conditions across Levels of Rurality. Health and Place 2009, 15:731-40.
  22. DeLia D: Distributional Issues In The Analysis Of Preventable Hospitalizations. Health Services Research 2003, 38(6 Pt 2):1761-79.
  23. Agency for Healthcare Research and Quality: Monitoring the Healthcare Safety Net. [http://www.ahrq.gov/data/safetynet/dat abooks/safetynet_key1.htm].
  24. Falik M, Needleman J, Wells BL, Korb J: Ambulatory Care Sensi- tive Hospitalizations And Emergency Visits: Experiences Of Medicaid Patients Using Federally Qualified Health Centers. Medical Care 2001, 39:551-61.
  25. Falik M, Needleman J, Herbert R, Wells B, Politzer R, Benedict MB: Comparative Effectiveness Of Health Centers As Regular Source Of Care: Application Of Sentinel ACSC Events As Performance Measures. Journal of Ambulatory Care Management 2006, 29:24-35.
  26. Epstein AJ: The Role Of Public Clinics In Preventable Hospital- izations Among Vulnerable Populations. Health Services Research 2001, 36:405-20.
  27. Garg A, Probst JC, Sease T, Samuels ME: Potentially Preventable Care: Ambulatory Care-Sensitive Pediatric Hospitalizations In South Carolina In 1998. Southern Medical Journal 2003, 96:850-8.
  28. Schoenman JA, Cheng CM, Evans WN, Blanchfield BB, Mueller CD: Do Hospital-Based Rural Health Clinics Improve The Per- formance Of The Parent Hospital? Policy Analysis Brief W series/ Project Hope, Walsh Center for Rural Health Analysis 1999, 2:1-4.
  29. Zhang W, Mueller KJ, Chen LW, Conway K: The Role Of Rural Health Clinics In Hospitalization Due To Ambulatory Care Sensitive Conditions: A Study In Nebraska. Journal of Rural Health 2006, 22:220-3.
  30. Agency for Healthcare Research and Quality: Safety Net Monitor- ing, Appendix B. Ambulatory Care Sensitive Conditions 2007 [http:// www.ahrq.gov/data/safetynet/billappb.htm\].
  31. Andersen RM: Revisiting the Behavior Model and Access to Medical Care: Does it Matter? Journal of Health and Social Behavior 1995, 36:1-10.
  32. Laditka JN, Laditka SB, Probst JC: More May be Better: Evidence of a Negative Relationship between Physician Supply and Hospitalization for Ambulatory Care Sensitive Conditions. Health Services Research 2005, 40:1148-66.
  33. Schreiber S, Zielinski T: The meaning of ambulatory care sensi- tive admissions: Urban and rural perspectives. Journal of Rural Health 1997, 13:276-284.
  34. Krakauer H, Jacoby I, Millman M, Lukomnik JE: Physician impact on hospital admission and on mortality rates in the Medicare population. Health Services Research 1996, 31:191-211.
  35. Ricketts TC, Randolph R, Howard HA, Pathman D, Carey T: Hospi- talization rates as indicators of access to primary care. Health and Place 2001, 7:27-38.
  36. Zhan C, Miller MR, Wong H, Meyer GS: The effects of HMO pen- etration on preventable hospitalizations. Health Services Research 2004, 39:345-61.
  37. Bindman AB, Chattopadhyay A, Osmond DH, Huen W, Bacchetti P: The impact of Medicaid managed care on hospitalizations for ambulatory care sensitive conditions. Health Services Research 2005, 40:19-38.
  38. US Census Bureau: Metropolitan and Micropolitan Statistical Areas. [http://www.census.gov/population/www/metroareas/met rodef.html].
  39. Laditka JN, Laditka SB, Mastanduno MP: Hospital Utilization for Ambulatory Care Sensitive Conditions: Health Outcome Disparities Associated with Race and Ethnicity. Social Science and Medicine 2003, 57:1429-1441.
  40. Laditka JN, Laditka SB: Race, Ethnicity, and Hospitalization for Six Chronic Ambulatory Care Sensitive Conditions in the United States. Ethnicity and Health 2006, 11:247-263.
  41. Laditka JN: Hazards of Hospitalization for Ambulatory Care Sensitive Conditions among Older Women: Evidence of Greater Risks for African Americans and Hispanics. Medical Care Research and Review 2003, 60:468-495.
  42. United States Census Bureau: Small Area Health Insurance Esti- mates: Model-based Estimates for Counties and States. [http://www.census.gov/did/www/sahie/data/index.html\].
  43. U.S. Census Bureau, Data Integration Division, Small Area Estimates Branch: Washington, DC
  44. Health Disparities Collaboratives: Background. [http://
  45. Hadley J, Cunningham P, Hargraves JL: Would Safety-Net Expan- sions Offset Reduced Access Resulting From Lost Insurance Coverage? Race/Ethnicity Differences. Health Affairs 2006, 25:1679-87.