Health Research & Educational Trust of New Jersey (HRET)
Research
Ongoing Projects
Access to Primary Care in New Jersey: Geographic Variation of Hospitalizations for Ambulatory Care Sensitive Conditions
Table of Contents:
Project Overview Access to primary healthcare continues to be an important health issue with significant economic ramifications. Individuals without access to primary health care do not receive timely care to prevent the onset of an illness, control an acute episode or manage a chronic condition, therefore, are at a greater risk of disability and morbidity/mortality due to preventable illnesses. The unattended medical conditions of individuals without proper access to primary and preventive healthcare often result in more severe episodes. This ultimately leads to more expensive treatment options, including hospital admissions for illnesses that could have been managed on an outpatient basis. The hospitalization rate for this group of illnesses, known as Ambulatory Care Sensitive (ACS) conditions, such as pneumonia or asthma, is now being used as a proxy to assess the performance of the outpatient delivery system in a geographic area. A high hospitalization rate for these conditions in one area may indicate inadequate and inaccessible primary care services in that area.
Recognizing the growing number of uninsured populations and their lack of access to healthcare as a societal issue with significant health and economic ramifications, HRET initiated an extensive research project in 1998 to study the issue. The primary goal of this two-year study was to provide information needed to improve access of the medically indigent and uninsured populations to primary healthcare services throughout the state of New Jersey.
The specific objectives of this study were to:
- Analyze geographic variation of hospitalization rates for ACS conditions for total and pediatric populations in 1995 and 1997 throughout the state of New Jersey;
- Identify ZIP codes where barriers to access to primary health care exist;
- Characterize the ACS conditions that result in the highest rate of hospitalizations in different areas and investigate the patterns of their change over time;
- Determine if barriers to access are the result of demographic and/or socioeconomic characteristics of the area or deficiencies in the health care delivery system; and,
- Identify areas where additional investigation is needed and investigate the factors that contribute to the problem in these areas and identify possible solutions/remedies.
Implementation of this study was supported by a grant from the Robert Wood Johnson Foundation.
Top of PageMethodologyPhase I of the study used a methodological approach called small area variation analysis and involved construction of population-based hospitalization rates for ACS conditions for 1995 and 1997 (using hospital discharge data, UB-92, and Census population estimates) for non-elderly (0-64 years of age) and pediatric (0-17 years of age) residents of New Jersey. Patients over 64 years of age were excluded from this study since almost all of them are covered by insurance, chiefly through Medicare. The aggregate ACS hospitalization rates were computed for state, counties and each small area/zip code and expressed as admissions per 1,000 population. To allow comparison across communities with various age compositions, the rates were age-adjusted. Data were also analyzed for some specific ACS conditions, i.e., asthma, diabetes, bacterial pneumonia, etc. The data were examined spatially across zip codes at each point in time, and temporally across time for each zip code. Using this method, areas with high ACS rates and serious problems of access to primary care were identified. Regression models determined the association of the area's socioeconomic factors with admission rates. To further investigate the problematic areas and identify specific individual, social, cultural and systemic barriers to primary care access at local levels, 10 focus groups with consumers and 11 focus groups with community leaders, public health officials, healthcare administrators, practitioners and primary care physicians were conducted in 11 geographic areas spanning 26 zip codes.
Top of PageMajor FindingsThrough this study, geographic variation of hospitalizations for ACS conditions for adults and pediatric admissions were analyzed for counties and small areas across the state and zip codes with the highest age-adjusted ACS hospitalization rates per 1000 population and barriers to accessing primary care were identified. Low income was found as the strongest predictor of high ACS hospitalization rates. The study confirmed that these rates in New Jersey were significantly higher than other states and dramatically higher in poorer communities of the state, a finding that raises a red flag about residents' access to primary healthcare. The focus groups in problematic areas discussed the causes of local access issues and recommended remedies and possible solutions to remove or alleviate them. Major identified obstacles were: hassles associated with the healthcare delivery system, inconvenience with physicians' office hours and locations, language and transportation barriers, and negative attitudes of providers. Based on the findings of both quantitative and qualitative studies, a series of recommendations was prepared for submission to the state government, policy makers and hospital/community health planners. See the study's executive summary, link below, for a snapshot of these recommendations and ask for the study's final report for the complete list.
Top of PageSelected Recommendations
System Improvements
- Design multidisciplinary clinics allowing adults and children to be seen at the same setting.
- Add more non-English-speaking staff to hospital clinics and other primary care settings.
- Utilize nurse practitioners and/or physician assistants in primary care settings to enhance provider hours.
- Offer more appointment slots to reduce waiting periods. Allow for "same day" appointments.
- Provide consumers easy phone access to healthcare providers.
- Add evening and weekend office hours to clinicians' practices that serve the Medicaid and "working poor" populations.
- Create more neighborhood-based and work site-based health clinics and mobile units. Consider setting up primary care clinics within school, church, other community-based organizational settings and large work sites of low-income employers.
- Establish contracts with Medicaid managed care providers to allow patients to fill prescriptions at clinic or hospital pharmacies to improve medication compliance.
- Provide more training for hospital or community outreach workers stationed in the emergency department, outpatient clinics, admission or cashier areas to assist patients' enrollment in NJ FamilyCare.
- Monitor all hospital admissions and emergency department visits for ACS conditions.
Education Initiatives
- Distribute a comprehensive directory of health resources/services and providers by a trained person/volunteer in the emergency department to consumers, to assist patients with selecting a primary care provider in their community.
- Continue to provide patient education classes on proper control, self-management, use of medications, diet and signs and symptoms of chronic conditions, such as asthma, diabetes, congestive heart failure and other leading causes of adult or pediatric ACS hospitalizations.
- Create educational materials in languages besides English and Spanish to provide better health education to New Jersey's ethnically diverse population, especially on managing the leading ACS conditions.
- Include cultural competency training for physicians, nurses and other healthcare workers through yearly hospital in-services. The training programs should be aimed at improving performance of providers and reducing the underlying distrust of consumers.
Top of PageNext StepsThe next phase of this study is designed to:
- Monitor ACS rates for 1999-2007;
- Investigate the patterns of their change from 1995 to 2007, with a focus on identified problematic areas;
- Conduct further investigation and more data analyses focusing on socioeconomic factors, mainly poverty, racial/ethnic mix of the communities and payer sources;
- Produce county and hospital-specific reports; and,
- Convene focus groups again, specifically from communities with persistent access problems, to assess the impact of interventions in combating access barriers, to assess patterns of change and to identify additional barriers.
The findings will provide public health planners and researchers, policymakers and government officials with a powerful analytical leverage and an opportunity to examine and evaluate the performance of the outpatient and primary care delivery system in different areas. They will help establish regional and local health priorities for more precise health planning, prevention and resource allocation purposes, targeting communities with significant access problems. Furthermore, the findings are expected to help hospitals assess their community's needs, plan appropriate service interventions and implement necessary programs. Analysis of the data for 1995-2007, using a longitudinal design, will help identify any possible trends. The eventual outcome of these efforts will be the design of an equitable healthcare delivery system that provides high quality ambulatory care and easy access to primary care on an outpatient basis for the medically indigent population, and saves the unnecessary costs of avoidable hospitalizations.
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