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This fifth report in the series on preventable hospitalizations examines, for the first time, the numbers of preventable emergency department (ED) visits, in addition to observation stays (introduced in the fourth report), and preventable hospitalizations. Also new to this report is a breakout of preventable: hospitalizations, observation stays, and ED visits by race.
From Fiscal Years 1998 and 1999 (FY98/FY99) to Fiscal Years 2002 and 2003 (FY02/FY03), preventable hospitalizations for all Massachusetts residents per 1,000 population increased 3%, but not as much as total hospitalizations (4.9%).1 Therefore, preventable hospitalization (PH) rates decreased relative to total hospitalization (TH) rates. The relative decrease was also true for people ages 0-64 and people ages 65 and older.
Perhaps the more unusual trend was the decrease in the number of observation stays. From FY98/FY99 to FY02/FY03, total observation stays decreased 14.7% and preventable observation stays decreased 26.5% for all ages. Part of this decrease could be attributed to Medicare’s change in outpatient reimbursement methodology. In 2002, Medicare began paying hospitals the same for observation stays and ED visits. This doesn’t explain, however, why preventable observation stay rates decreased relative to total observation stay rates and why total observation stay and preventable observation stay rates decreased for payers other than Medicare.
Having health insurance does not equate to access to, or appropriate use of, high quality health care. Some payers, particularly Medicaid, had higher rates of preventable visits per population than the uninsured.
In FY02/FY03, blacks had the most PHs per 1,000 population (21.3) followed by whites (18.2), and Hispanics (12.6). The differences among races for preventable and total ED visits per 1,000 population were much greater. The preventable ED rate per 1,000 blacks was nearly two and a half times that of whites, and the rate for Hispanics was more than twice that of whites. A higher incidence of some preventable conditions among blacks and Hispanics may contribute to these differences, but many of the differences are likely due to blacks’ and Hispanics’ greater dependence on the ED for more of their health care needs. Blacks’ and Hispanics’ overall use of the ED (preventable and other) is also disproportionately higher than that of whites: roughly two and a half, and two, times higher, respectively.
The time of day that people visit the ED for an ambulatory care sensitive condition is very similar across races. Of five time periods within a day (midnight to early morning, early morning, day time, evening, and late evening), 40% to 44% (depending upon the race of patients) of ED visits for treatment of a preventable event occurred during the day. The next most frequent time was early evening, which accounted for 22% to 24% of preventable ED visits.
Small Area Analysis Poorer areas in Massachusetts continue to be home to people who are hospitalized more frequently for preventable conditions. There was little variation among PH rates (per 1,000 population, age adjusted) in small areas between FY98/FY99 and FY02/FY03. Most areas that had relatively high PH rates (for all ages) in FY98/FY99 experienced high rates again in FY02/FY03. Although declining PH and observation stay rates relative to total hospitalization and observation stay rates is good news, clearly there is considerable room for improving access to high quality primary care to Massachusetts residents.