Lack of Primary and Preventive Care Sends Thousands to Hospital

Better access to primary health care and prevention programs could have kept thousands of California adults out of hospitals, according to a new statewide analysis.

According to new data released last week by the Office of Statewide Health Planning and Development, there were more than 335,000 adult hospitalizations in California that could have been avoided if the patient had seen a doctor sooner.

According to the state agency, so-called “preventable hospitalizations” are an indication of systemic shortcomings related to access to quality primary care.

“These are people going into the hospital that probably shouldn’t be if they were getting good primary care up front,” said Michael Kassis, a research specialist with the office.

Poor environmental factors and a failure to follow medical treatment also could prompt these avoidable hospital stays, the agency said.

The latest figures are based on an analysis of 2009 hospital inpatient discharges by state-licensed facilities of 13 “prevention quality indicators,” or readily treatable medical conditions such as chest pains and dehydration.

There’s been a slight uptick in preventable hospitalizations in California since 2008, when there were 317,050 cases. In 1999, there were 399,113 cases.The financial implications of these avoidable hospitalizations can be significant. A report [PDF] published last year by the Centers for Medicare & Medicaid Services noted that 26 percent of all patients who are dually eligible for Medicare and Medicaid had avoidable hospitalizations – at a cost of more than $7 billion to taxpayers in 2011.

California had fewer preventable hospitalizations among this population than the national average, and based on the new state data, avoidable hospitalizations cost the California-based health care system an estimated $3.6 billion per year.

Although these costs are associated with patients who are both publicly and privately insured, the state agency said avoidable hospitalizations ultimately affect all Californians.

“Outpatient care costs less than hospital care, resulting in significant cost savings for health plans/insurers, employers, government and the ultimate payer – all of us,” according to a 2010 report on preventable hospitalizations published by the office.

The new California data is also available by county, with rural counties like Del Norte, Glenn and San Joaquin experiencing among the highest five-year averages of preventable hospitalizations for bacterial pneumonia, diabetes-related amputations and chronic obstructive pulmonary disease.

Los Angeles residents had rates of preventable hospitalizations above the state average for conditions such as long-term complications of diabetes, hypertension, congestive heart failure and adult asthma.

“The reason it’s good to have this data is that it forces us to look upstream and understand where there are missed opportunities to address these events and think about how we can develop systemic approaches to reducing them,” said Dr. Jonathan E. Fielding, director of the Los Angeles County Department of Public Health and the county's health officer.

Los Angeles is home to about 2.2 million [PDF] uninsured non-elderly adults and children, which Fielding said contributes to the area’s preventable hospitalizations.

“I think there needs to be more emphasis on primary care, but you can’t emphasize that unless you have the means to access it,” he said. “In the state as a whole, and particularly in Los Angeles County, there are too many adults who lack health insurance and don’t get the care they need in a timely fashion, so they result in preventable hospitalizations. Good access to primary care can help avert these hospitalizations."

Among children, there were an additional 53,897 preventable hospitalizations in 2009 related to five medical conditions, such as low birth weight and short-term complications from diabetes. Imperial County had high rates of pediatric gastroenteritis and urinary tract infections.

Jeremy Cantor of the Oakland-based Prevention Institute said these statistics illustrates the importance of prevention programs.

“All of these things are preventable to some extent, so the fact that the numbers are above zero means that there needs to be more focus on prevention,” he said. “What this means – not just in terms of health care costs, but also productivity and days that people have to take off work – has a huge impact on the state.”

But funds for prevention programs recently have become more scarce. Last week, Congress passed a bill that extends the payroll tax cut and forestalls payment cuts to doctors who accept Medicare by trimming about $5 billion from the federal Prevention and Public Health Fund over the next decade. In 2010, California received about $12 million [PDF] from the fund, which was created under the federal health reform law.

Cantor added that environmental and social factors that affect health can’t be overlooked.

“What can be misleading is that the implication is that these rates are determined by a patient’s experience in clinical settings,” he said. “That is far from the case. Part of the picture is access to quality clinical care. But it’s also related to exposures to toxins, and economic and educational opportunities, the lack of access to places to be physically active and a whole spectrum of factors that shape health outcomes.”

The data on preventable hospitalizations is not an indication of poor hospital care. But the 2009 data recently released by the Office of Statewide Health Planning and Development also examined patient safety [PDF] and found 334 incidents in which gauze or other surgical equipment was left inside the body during an operation and 8,230 cases in which patients were accidentally cut or punctured during their hospital stay.