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Show in a small town, cultural barriers such as taboos against physical examinations by a member of the opposite sex, or behavioral barriers such as delayed care-seeking, etc., in addition to inability to pay. If public assistance is available, access may still not be assured due to confusion about eligibility requirements of multiple public programs, movement back and forth between public programs due to changes in eligibility, waiting periods before benefits begin The Utah CHIP proposal addresses financial barriers to access to primary care and other health services by providing health insurance to uninsured children up to age 19 who live in households up to 200% of poverty level. ACS Hospitalizations as a Measure of Access to Primary Care One administrative indicator of a population's access to primary care is its rate of hospitalizations for ambulatory care sensitive (ACS) conditions. This measure was proposed by the Institute of Medicine (Millman, 1993). Variants have been extensively explored and validated (Paul-Shaheen, Clark, & Williams, 1987). Approximately 10-15% of Utah hospitalizations are for these conditions, including asthma, diabetes, immunizable conditions, pneumonia, congestive heart failure, and others (Casanova & Starfield, 1995; Millman, 1993). They represent hospitalizations, some of which might reasonably have been prevented if adequate primary care had been received in time. An elevated ACS hospitalization rate in a small geographic area suggests that a population, e.g., the residents of a county, may not be receiving adequate and timely primary care, whether due to barriers such as those described above or other reasons. This conclusion is valid when other interpretations, primarily higher prevalence of the underlying condition, are unlikely (Silver, Magill, & Babitz, 1997). ACS hospitalizations are higher in low-income areas (Billings et al., 1993; Bindman et al., 1995). Medicaid enrollees have ACS admission rates intermediate between the uninsured and those with private insurance, suggesting that some but not all barriers to primary care are removed by increased insurance coverage (Billings, Anderson, & Newman, 1996; Weissman, Gatsonis, & Epstein, 1992). Other factors may be clinic and outpatient department hours, outreach to make the public aware of available resources, education targeted at patient compliance, transportation issues, language, and other sociocultural barriers (Billings & Teicholz, 1990). Also, some ACS hospitalizations are elevated in rural areas (Schreiber & Zielinski, 1997; Silver etal, 1997). ACS hospitalization rates are calculated using population figures available from census data, insurance enrollment figures, and the Hospital Discharge Data. The latter are administrative data which have been computerized in Utah since 1992, by the Utah Department of Health Office of Health Data Analysis. They provide a snapshot of Utah hospitalizations to compare to national figures (Rolfs & Xu, 1995), benchmarks for individual hospitals (Utah Office of Health Care Data Analysis, 1996), and information regarding where counties' hospitalization dollars are spent (Utah Association of Health Care Providers, 1997). ACS hospitalization rates do not necessarily trend in the same direction for different diagnostic conditions. When several indicators are increased in a small area, the cause may be a general lack of access, such as a health provider shortage. When hospitalization rates for one or a few ACS conditions are elevated, disease-specific solutions may be indicated (Rolfs & Xu, 1995). When disease-specific ACS hospitalization rates do trend in the same direction, pooling them as an overall ACS hospitalization rate may allow smaller areas to be compared. However, disease-specific rates are also useful, when numbers of events are statistically adequate. As a screening method, a finding of elevated ACS hospitalization rates in a county compared to the statewide rate leads to a community assessment to seek reasons for the pattern, preparatory to a policy solution focused on removal of the specific barrier to access. In a program evaluation, the rate of ACS hospitalizations for program enrollees might be compared to that for non-enrollees as an easily-obtainable administrative measure of programmatic elimination or inadvertent production of barriers to access to primary care. ACS Hospitalizations in Children The ACS hospitalization rate also provides one indicator of presence or absence of barriers to access to primary care in children (Casanova & Starfield, 1995; Perrin et al., 1989). However, most of pediatric care is well-child care. Evaluative indices developed from hospitalization data can not paint a complete picture of the effects of increased insurance coverage on pediatric health care, but they might represent one tool in an evaluation scenario. 52 |