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)

Lichtl et al. BMC Health Services Research (2017) 17:731 DOI 10.1186/s12913-017-2672-7 RESEARCH ARTICLE Open Access 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 crosssectional medical records study (2015) Célina Lichtl1, Thomas Lutz2, Joachim Szecsenyi1 and Kayvan Bozorgmehr1* Abstract Background: Hospitalizations for ambulatory care sensitive (ACS) conditions are established indicators for the availability and quality of ambulatory care. 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. Methods: Using anonymous account data, all children admitted to the University Hospital Heidelberg in 2015 were included in our study. A unique cost unit distinguished asylum seekers residing in a nearby reception center (exposed) from the children of the general population. We adapted international lists of ACS conditions and calculated the prevalence of ACS hospitalizations and the utilization of emergency outpatient services for ACS conditions, attributable fractions among the exposed (Afe) and the population attributable fraction among total admissions (PAF) for each outcome. Differences in the prevalence of each outcome between exposed and controls were analyzed in logistic regression models adjusted for sex, age group and quarterly admission. Results: Of the 32,015 admissions in 2015, 19.9% (6287) were from inpatient and 80.1% (25,638) from outpatient care. In inpatient care, 9.8% (622) of all admissions were hospitalizations for ACS conditions. The Afe of ACS hospitalizations was 46.57%, the PAF was 1.12%. Emergency service use for ACS conditions could be identified in 8. 3% (3088) of all admissions (Afe: 79.57%, PAF: 5.08%). The odds ratio (OR) of asylum-seeking children being hospitalized for ACS conditions in comparison to the control group was 1.81 [95% confidence interval, CI: 1.02; 3.2]. The OR of the asylumseeking population compared to the general population for the utilization of emergency service use for ACS conditions was 4.93 [95% CI: 4.11; 5.91]. (Continued on next page) * Correspondence: 1 Department of General Practice and Health Services Research, University Hospital Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lichtl et al. BMC Health Services Research (2017) 17:731 Page 2 of 9 (Continued from previous page) Conclusions: Asylum-seeking children had significantly higher odds of ACS hospitalization and of utilization of emergency outpatient services for ACS conditions. Using the concept of ACS conditions allowed measuring the strength of primary care provided to this local asylum-seeking population. This approach could help to compare the strength of primary care provision in different locations, and allow an objective. Keywords: Ambulatory care sensitive conditions, Ambulatory care sensitive hospitalizations, ACS, ACSC, ACSH, Asylum seeker, Children, Minor, Pediatric, Preventable, Avoidable Background 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 (...truncated)