Abstract
Research has suggested that accessible primary healthcare may help control hospitalization for certain conditions that are often considered either preventable or treatable through primary healthcare. However, only limited research has tested this widely accepted hypothesis. We extend research on preventable hospitalization in the framework of cost-effectiveness analysis. Using hospitalization data from South Carolina, we show how access to primary healthcare may affect the volume and cost of hospitalizations for ambulatory care sensitive conditions. Our statistical models for effectiveness and cost take advantage of spatial methods to adjust for neighborhood characteristics. This adjustment also addresses correlations among variables describing each given area, providing appropriate results despite those correlations. We also use propensity scores to adjust for county level variation in access to primary healthcare. We observe that the mean differential volume and cost of lower extremity amputation associated with diabetes was significantly lower in areas served by community health centers than in other areas. This result provides support for the hypothesis that increasing access to primary healthcare may help to control the volume and cost of preventable hospitalization for some conditions.
Similar content being viewed by others
References
Agency for Healthcare Resessarch and Quality (2001) Research and Quality: Refinement of the HCUP Quality Indicators. AHRQ publication no 01-0035, Rockville (2001)
Ansari, Z., Laditka, J.N., Laditka, S.B.: Access to health care and hospitalization for ambulatory care sensitive conditions. Med. Care Res. Rev. 63, 719–741 (2006)
Austin, P.C., Mamdani, M.M., Stukel, T.A., Anderson, G.M., Tu, J.V.: The use of the propensity score for estimating treatment effects: administrative versus clinical data. Stat. Med. 24, 563–1578 (2005)
Basu, J., Friedman, B., Burstin, H.: Primary care, MHO enrollment, and hospitalization for ambulatory care sensitive conditions: a new approach. Med. Care 40, 1260–1269 (2002)
Begley, C.E., Vojvodic, R.W., Seo, M., Barua, K.: Emergency room use and access to primary care: evidence from Houston, Texas. J. Health Care Poor Underserved 17, 610–624 (2006)
Bennett, K.J., Moore, C.G., Probst, J.C.: Estimating uncompensated care charges at rural hospital emergency department. J. Rural Health 23, 258–263 (2007)
Brookhart, M.A., Sturmer, T., Glynn, R.J., Rassen, J., Schneeweiss, S.: Confounding control in healthcare database research challenges and potential approaches. Med. Care 48, S114–S120 (2010)
Choudhry, L., Douglass, M., Lewis, J., Olson, C.H., Osterman, R., Shah, P.: The impact of community health centers & community-affiliated health plans on emergency department use. National Association of Community Health Centers Inc, USA (2007)
Christiansen, C.L., Morris, C.N.: Hierarchical Poisson regression modeling. J. Am. Stat. Assoc. 92, 618–632 (1997)
D’Agostino, R.B., D’Agostino, R.B.: Estimating treatment effects using observational data. J. Am. Med. Assoc. 297, 314–316 (2007)
D’Agostino, J.: Propensity score methods for bias reduction in the comparison of a treatment to a nonrandomized control group. Stat. Med. 17, 2265–2281 (1999)
Falik, M., Needleman, J., Herbert, R., Wells, B., Politzer, R., Benedict, M.B.: Comparative effectiveness of health centers as regular source of care: application of sentinel ACSC events as performance measures. J. Ambul. Care Manage. 29, 24–35 (2006)
Fenwick, E., O’Brien, B.J., Briggs, A.: Cost-effectiveness acceptability curves—facts, fallacies and frequently asked questions. Health Econ. 13, 405–415 (2004)
Gardiner, J.C., Luo, Z., Liu, L., Bradley, C.J.: A stochastic framework for estimation of summary measures in cost-effectiveness analyses. Exp. Rev. Pharmacoecon. Outcomes Res. 6, 347–358 (2006)
Hade, E.M., Lu, B.: Bias associated with using the estimated propensity score as a regression covariate. Stat. Med. 33, 74–87 (2014)
Hossain, M.M., Graham, P., Gower, S., Davis, P.: Hierarchical generalised linear models with time-dependent clustering: assessing the effect of health sector reform on patient outcomes in New Zealand. Health Serv. Outcomes Res. Methodol. 4, 169–186 (2003)
Hossain, M.M., Laditka, J.N.: The influence of rurality on the volume of non-urgent emergency department visits. Spat. Spatiotemporal Epidemiol. 2, 311–319 (2011)
Hossain, M.M., Laditka, J.N.: Using hospitalization for ambulatory care sensitive conditions to measure access to primary care: an application of spatial structural equation modeling. Int. J. Health Geogr. 8, 51 (2009)
Indurkhya, A., Mitra, N., Schrag, D.: Using propensity scores to estimate the cost-effectiveness of medical therapies. Stat. Med. 25, 1561–1576 (2006)
Millman, M. (ed.): Access to Health Care in America. National Academy Press, Institute of Medicine, Washington (1993)
Jiang, H.J., Russo, C.A., Barrett, M.L.: Nationwide frequency and costs of potentially preventable hospitalizations, HCUP Statistical brief # 72. US Agency for Healthcare, Rockville (2009)
Jin, X., Banerjee, S., Carlin, B.P.: Order-free co-regionalized areal data models with application to multiple-disease mapping. J. R. Stat. Soc. B 69, 817–838 (2007)
Ku, L., Richard, P., Dor, A., Tan, E., Shin, P., Rosenbaum, S.: Strengthening Primary Care to Bend The Cost Curve: The Expansion Of Community Health Centers Through Health Reform. The George Washington University School of Public Health and Health Services, Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Washington (2010)
Laditka, J.N., Laditka, S.B.: Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA. Ethn. Health 11, 247–263 (2006)
Lawson, A.B.: Statistical methods in spatial epidemiology, Wiley Series in Probability and Statistics. John Wiley, Chichester (2006)
Liu, L., Conaway, M.R., Knaus, W.A., Bergin, J.D.: A random effects four-part model, with application to correlated medical costs. Comput. Stat. Data Anal. 52, 4458–4473 (2008)
Lothgren, M., Zethraeus, N.: Definition, interpretation and calculation of cost- effectiveness acceptability curves. Health Econ. 9, 623–630 (2000)
Luo, Z., Gardiner, J.C., Bradley, C.J.: Evaluating propensity score methods in comparison with randomized trials: pitfalls and prospects. Med. Care Res. Rev. 67, 528–554 (2010)
Mitra, N., Indurkhya, A.: A propensity score approach to estimating the cost-effectiveness of medical therapies from observational data. Health Econ. 14, 805–815 (2005)
Nixon, R.M., Thompson, S.G.: Methods for incorporating covariate adjustment, subgroup analysis and between-centre differences into cost-effectiveness evaluations. Health Econ. 14, 1217–1229 (2005)
O’Hagan, A., Stevens, J.W.: A framework for cost-effectiveness analysis from clinical trial data. Health Econ. 10, 303–315 (2001)
Parchman, M.L., Culler, S.D.: Preventive hospitalizations in primary care shortage areas. An analysis of vulnerable Medicare beneficiaries. Arch. Fam. Med. 8, 487–491 (1999)
Pittard, W.B., Laditka, J.N., Laditka, S.B.: Associations between maternal age and infant health outcomes among medicaid-insured infants in South Carolina: mediating effects of socioeconomic factors. Pediatrics 122, E100–E106 (2008)
Probst, J.C., Laditka, J.N., and Laditka, S.B.: Community Health Center and Rural Health Clinic Presence Associated with Lower County-Level Hospitalization Rates for Ambulatory Care Sensitive Conditions, Report prepared under Grant No 6 UIC RH 03711-01 with the Federal Office of Rural Health Policy, Health Resources and Services Administration, 2007
Richman, I.B., Clark, S., Sullivan, A.F., Camargo Jr, C.A.: National study of the relation of primary care shortages to emergency department utilization. Soc. Acad. Emerg. Med. 14, 279–282 (2007)
Smith-Campbell, B.: Emergency department and community health center visits and costs in an uninsured population. J. Nurs. Scholarsh. 37, 80–86 (2005)
Smith-Campbell, B.: Access to health care: effects of public funding on the uninsured. J. Nurs. Scholarsh. 32, 295–300 (2000)
Spiegelhalter, D., Best, N., Carlin, B., Linde, A.: Bayesian measures of model complexity and fit (with discussion). J. R. Stat. Soc. B 64, 583–639 (2002)
Spiegelhalter, D., Thomas, A., Best, N., Lunn, D.: Win BUGS User Manual—Version 1.4.3 Cambridge. MRC Biostatistics Unit, Institute of Public Health, UK (2003)
Taylor, J.: The Fundamental of Community Health Centers, NHPF Background Paper. The George Washington University, Washington DC (2004)
US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions: Area Resource File (ARF). Rockville (2012)
Willan, A.R., Briggs, A.H.: Statistical Analysis of Cost-effectiveness Data. John Wiley & Sons Ltd, Chichester (2006)
Acknowledgments
The authors thank the Editor and a reviewer for their many constructive and insightful comments that improved this manuscript.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Hossain, M.M., Laditka, J.N. & Gardiner, J.C. The economic benefits of community health centers in lowering preventable hospitalizations: a cost-effectiveness analysis. Health Serv Outcomes Res Method 15, 23–36 (2015). https://doi.org/10.1007/s10742-014-0129-6
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10742-014-0129-6