Original Article

Ambulatory Care-sensitive Conditions: Clinical Outcomes and Impact on Intensive Care Unit Resource Use

Authors: John Burr, MD, Glenda Sherman, RN, Donna Prentice, MSN, Cherie Hill, BS, Victoria Fraser, MD, Marin H. Kollef, MD

Abstract

Background: We identified risk factors and clinical outcomes associated with ambulatory care-sensitive conditions requiring intensive care unit (ICU) admission.


Methods: This prospective cohort study included 4,144 patients admitted to the medical ICU of an urban teaching hospital during a 3-year period.


Results: A total of 627 patients were classified as having ambulatory care-sensitive conditions (ie, potentially preventable ICU admissions). Black race, decreasing Acute Physiology and Chronic Health Evaluation II (APACHE II) score, younger age, female sex, and absence of immunodeficiency were independently associated with ambulatory care-sensitive conditions. Patients classified as having ambulatory care-sensitive conditions accounted for 2,006 ventilator days, 2,508 ICU days, and 5,392 hospital days. The hospital mortality rate was statistically lower for patients with ambulatory care-sensitive conditions than for patients without these conditions. Patients classified as having ambulatory care-sensitive conditions were also statistically more likely than other patients to lack health insurance and to sign out of the hospital against medical advice.


Conclusion: Patients with ambulatory care-sensitive conditions account for a substantial portion of all admissions to the intensive care unit. These data suggest that interventions aimed at preventing such admissions could improve ICU bed use.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient: Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease—Can we meet the requirements of an aging population? JAMA 2000; 284: 2762–2770.
 
2. White J. Uses and abuses of long-term Medicare cost estimates. Health Aff (Millwood) 1999; 18: 63–79.
 
3. Iglehart JK. The American health care system: Medicare. N Engl J Med 1999; 340: 327–332.
 
4. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet 2000; 355: 1138–1142.
 
5. Darchy B, Le Miere E, Figueredo B, Bavoux E, Domart Y. Iatrogenic diseases as a reason for admission to the intensive care unit: Incidence, causes, and consequences. Arch Intern Med 1999; 159: 71–78.
 
6. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282: 267–270.
 
7. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: Morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol 1996; 17: 552–557.
 
8. Ordonez GA, Phelan PD, Olinsky A, Robertson CF. Preventable factors in hospital admissions for asthma. Arch Dis Child 1998; 78: 143–147.
 
9. Michalsen A, Konig G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart 1998; 80: 437–441.
 
10. Rauh RA, Schwabauer NJ, Enger EL, Moran JF. A community hospital-based congestive heart failure program: Impact on length of stay, admission and readmission rates, and cost. Am J Manag Care 1999; 5: 37–43.
 
11. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985; 13: 818–829.
 
12. Sporer KA. Acute heroin overdose. Ann Intern Med 1999; 130: 584–590.
 
13. Bindman AB, Grumbach K, Osmond D, Komaromy M, Vranizan K, Lurie N, et al. Preventable hospitalizations and access to health care. JAMA 1995; 274: 305–311.
 
14. Gage BF, Boechler M, Doggette AL, Fortune G, Flaker GC, Rich MW, et al. Adverse outcomes and predictors of underuse of antithrombotic therapy in Medicare beneficiaries with chronic atrial fibrillation. Stroke 2000; 31: 822–827.
 
15. Parchman ML, Culler SD. Preventable hospitalizations in primary care shortage areas: An analysis of vulnerable Medicare beneficiaries. Arch Fam Med 1999; 8: 487–491.
 
16. Hannan EL, van Ryn M, Burke J, Stone D, Kumar D, Arani D, et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care 1999; 37: 68–77.
 
17. Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988. Am J Public Health 1995; 85: 352–356.
 
18. Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer. N Engl J Med 1993; 329: 326–331.
 
19. Kollef MH, Ward S. The influence of access to a private attending physician on the withdrawal of life-sustaining therapies in the intensive care unit. Crit Care Med 1999; 27: 2125–2132.
 
20. Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med 1993; 329: 621–627.
 
21. Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe, controlled hypertension in an inner-city minority population. N Engl J Med 1992; 327: 776–781.
 
22. Simon MS, Gimotty PA, Moncrease A, Dews P, Burack RC. The effect of patient reminders on the use of screening mammography in an urban health department primary care setting. Breast Cancer Res Treat 2001; 65: 63–70.
 
23. Escalante A, Espinosa-Morales R, del Rincon I, Arroyo RA, Older SA. Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status. Arthritis Rheum 2000; 43: 390–399.
 
24. Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: Voltage drops from potential to delivered quality. JAMA 2000; 284: 2100–2107.
 
25. Katz SJ, Hofer TP. Socioeconomic disparities in preventive care persist despite universal coverage: Breast and cervical cancer screening in Ontario and the United States. JAMA 1994; 272: 530–534.
 
26. Hsia J, Kemper E, Kiefe C, Zapka J, Sofaer S, Pettinger M, et al. The importance of health insurance as a determinant of cancer screening: evidence from the Women's Health Initiative. Prev Med 2000; 31: 261–270.
 
27. Parker JD, Schoendorf KC. Variation in hospital discharges for ambulatory care-sensitive conditions among children. Pediatrics 2000; 106 (4 Suppl): 942–948.
 
28. LaVeist TA, Nickerson KJ, Bowie JV. Attitudes about racism, medical mistrust, and satisfaction with care among African American and white cardiac patients. Med Care Res Rev 2000; 57 (Suppl 1): 146–161.
 
29. Galavotti C, Richter DL. Talking about hysterectomy: the experiences of women from four cultural groups. J Womens Health Gend Based Med 2000; 9 (Suppl 2): S63–S67.
 
30. Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med 2000; 160: 2717–2728.