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Show Physicians' Perceptions of Non-Medical Variables Influencing the Decision to Hospitalize Elderly Patients with Ambulatory-Care Sensitive Conditions Marlene J. Egger, Ph.D. Marc E. Babitz, M.D. Mary Bishop, M.B.A. Abstract BACKGROUND. Hospitalization rates for chronic and acute ambulatory care sensitive conditions (ACSCs) were proposed by the Institute of Medicine as indices of access to care. Previous research showed a correlation with self-reported access and provider supply but not physician practice style when other factors were controlled. The present study developed and validated self-report measures of physician practice style to compare urban/rural practice styles in the rural/frontier inter-mountain west. METHODS. Paper patient scenarios involving one chronic and two acute ACSCs were rated by Utah physicians regarding the influence of pro-outpatient or pro-inpatient non-medical factors on the decision to admit in an equivocal case. Scales of pro-outpatient and pro-inpatient non-medical factors were developed, validated, and used to compare urban vs. rural/frontier responses. RESULTS. 33 urban and 29 rural physicians responded to the survey (30% response). Propensity to hospitalize equivocal cases varied with specific non-medical factors. Pro-outpatient factors were not homogeneously rated across diagnoses. A pro-inpatient summary scale was reliable, valid, and had significantly greater influence on self-rated rural/frontier admissions decisions than urban ones (p=0.041). CONCLUSIONS. Pro-inpatient non-medical factors appear to influence the self-reported decision to hospitalize patients with ACSCs more consistently than pro-outpatient non-medical factors in an inter-mountain west sample of physicians. Their influence appears stronger in rural/frontier areas. Replication in a larger sample would be desirable. Introduction Hospitalization constituted 40% of the nation's personal health care spending in 1995 (Levit, Lazenby, Braden et al., 1995). Variability in patterns of hospitalization was first reported by Wennberg (Billings et al., 1993; Fisher et al., 1992; Parchman, 1995; Paul-Shaheen et al., 1987; Weissman et al, 1992; Wennberg, 1993). Expenditures for hospitalization in 1995 were almost twice as high as those for the combined services of primary and specialty care physicians (Levit, Lazenby, Braden et al, 1995). Thus, an exchange of lowered hospitalization costs for increased out-patient physician services could be expected to reduce the nation's health care bill. This paper reports the perceptions of Utah physicians that non-medical factors are part of the constellation of issues which signal that hospitalization is becoming unavoidable. It suggests that it may be possible to reduce hospitalizations, and hence costs of care, for ambulatory care sensitive conditions if access barriers can be addressed by developing workable alternatives to hospitalization. Considerable variation in hospitalization rates in small adjacent geographical areas has been observed for a variety of diagnoses and procedures since Wennberg's ground-breaking studies of the 1970s (Billings et al., 1993; Fisher et al., 1992; Parchman, 1995; Paul-Shaheen et al., 1987; Weissman et al, 1992; Wennberg, 1993). Wennberg remarked that if the hospitalization rates of the state of Oregon in 1988 could be made to match the rates in its capital city, Salem, the savings would cover the state's entire Medicaid program (Fisher et al, 1992; Wennberg, 1993). Wennberg's emphasis was on practice variation. Diagnoses such as hip fracture, colon cancer and inguinal hernia exhibit a high degree of consensus regarding necessity and timing of hospitalization. In contrast, procedures such as tonsillectomy, hysterectomy, and prostatectomy invoke a high degree of medical uncertainty or lack of national consensus, regardless of single-site agreement, concerning when the procedure is required and sometimes considerable patient choice, with concomitant variation in hospitalization rates (Wennberg and Gittelson, 1975). Perhaps the greatest potential impact of adequate primary care in reducing the nation's hospitalization costs and increasing access lies in the treatment of pneumonia, diabetes, congestive heart failure, and other acute and chronic ambulatory care sensitive conditions, or ACSCs (Millman, 1993). These conditions incur consequences requiring hospitalization if the patient does not receive adequate outpatient care. Hospitalizations for various ACSCs have 19 |