Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study

Gygli et al. BMC Health Services Research (2021) 21:849 https://doi.org/10.1186/s12913-021-06876-5 RESEARCH Open Access Regional variation of potentially avoidable hospitalisations in Switzerland: an observational study Niklaus Gygli1,2, Franziska Zúñiga1 and Michael Simon1,3* Abstract Background: Primary health care is subject to regional variation, which may be due to unequal and inefficient distribution of services. One key measure of such variation are potentially avoidable hospitalisations, i.e., hospitalisations for conditions that could have been dealt with in situ by sufficient primary health care provision. Particularly, potentially avoidable hospitalisations for ambulatory care-sensitive conditions (ACSCs) are a substantial and growing burden for health care systems that require targeting in health care policy. Aims: Using data from the Swiss Federal Statistical Office (SFSO) from 2017, we applied small area analysis to visualize regional variation to comprehensively map potentially avoidable hospitalisations for five ACSCs from Swiss nursing homes, home care organisations and the general population. Methods: This retrospective observational study used data on all Swiss hospitalisations in 2017 to assess regional variations of potentially avoidable hospitalisations for angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, diabetes complications and hypertension. We used small areas, utilisation-based hospital service areas (HSAs), and administrative districts (Cantons) as geographic zones. The outcomes of interest were age and sex standardised rates of potentially avoidable hospitalisations for ACSCs in adults (> 15 years). Our inferential analyses used linear mixed models with Gaussian distribution. Results: We identified 46,479 hospitalisations for ACSC, or 4.3% of all hospitalisations. Most of these occurred in the elderly population for congestive heart failure and COPD. The median rate of potentially avoidable hospitalisation for ACSC was 527 (IQR 432–620) per 100.000 inhabitants. We found substantial regional variation for HSAs and administrative districts as well as disease-specific regional patterns. Conclusions: Differences in continuity of care might be key drivers for regional variation of potentially avoidable hospitalisations for ACSCs. These results provide a new perspective on the functioning of primary care structures in Switzerland and call for novel approaches in effective primary care delivery. Keywords: Potentially avoidable hospitalisations, Ambulatory care sensitive conditions, Switzerland, Primary health care, Regional variation * Correspondence: 1 Faculty of Medicine, Department of Public Health, Institute of Nursing Science, University of Basel, Bernoullistr. 28, CH-4056 Basel, Switzerland 3 Nursing and Midwifery Research Unit, Department of Nursing, University Hospital Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. 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 in a credit line to the data. Gygli et al. BMC Health Services Research (2021) 21:849 Background Primary health care is vital to population health. However, regional variability of its quality and accessibility may lead to unequal and inefficient distribution of services. One key measure of this variability is the rate of avoidable hospitalizations, i.e., those for conditions that could have been treated with appropriate chronic disease management in place in primary health care [1–3]. In addition to incurring considerable extra costs, treating these conditions in hospital disrupts the affected patients’ normal care provision [4, 5]. Ambulatory care-sensitive conditions (ACSC) support the measurement and comparison of rates of potentially avoidable hospitalisations. These were originally defined by international organisations such as the Organisation for Economic Co-operation and Development (OECD) and further developed by scientific experts [3]. Potentially avoidable hospitalisations for ACSCs are most common in the elderly population and increase with age [6, 7]. Chronic conditions account for up to 60% of total potentially avoidable hospitalisations and their respective costs [6, 7]. Additionally, ACSCs account for up to 48% of annual emergency department visits and 20% of overall hospitalisations [7–10]. The total cost of potentially avoidable hospitalisations for ACSCs are a growing economic burden for health care systems [6, 7, 11]. Approximately 42% of hospitalized nursing home residents are referred for ACSCs, thus generating unnecessary costs of up to 102 million Swiss francs annually in Switzerland [12]. Furthermore, there is a socio-economic gradient, with lower ACSC rates in higher income regions [13] However, it is unclear how different settings and respective primary healthcare providers handle ACSC. Therefore, especially for the elderly population, it is vital not only to assess total rates of avoidable ACSCbased hospitalisations, but also to differentiate between the involved settings. We identified five conditions that are both commonly used in health services research literature and highly prevalent amongst chronically ill populations [1–3, 5–7, 10]. In descending order of occurrence, these are: congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes complications, hypertension and angina pectoris. A large proportion of hospitalisations for these conditions are deemed preventable, i.e., they can normally be positively influenced via effective chronic disease management by primary care providers [10]. Switzerland offers a unique opportunity to explore regional variations in potentially avoidable hospitalisations. Because of its status as a confederation, Swiss health law includes relatively high levels of regional autonomy, allowing regions to establish their own care structures and approaches [14]. Mandatory health insurance with Pag (...truncated)