Hospitalizations of nursing home residents who were admitted with an ACSC were frequent and expensive for the Swiss health-care system. We observed approximately 42% of nursing home admissions due to an ACSC, half of which were attributable to falls and trauma. These findings are similar to study reports from the USA, Canada, and Sweden, where the prevalence of ACSCs excluding falls ranged between 16 and 38% (Grabowski et al. 2007; Kirsebom et al. 2014; McAndrew et al. 2015) and between 40 and 55% for studies including falls (Walker et al. 2009; Walsh et al. 2012). Our results were also similar to findings from a Swedish study documenting 25% of ED visits due to falls from nursing home residents (Kirsebom et al. 2014). In contrast, Ouslander et al. found that 67% of hospitalizations were avoidable, without considering falls, using a structured review of medical charts by experts (Ouslander et al. 2010).
Results for our cost analysis showed that admissions for ACSCs were rather costly, ranging between 105 million CHF and 89 million CHF assuming base rates of 11,200 CHF and 9500 CHF, respectively. This constitutes approximately 40% of the total costs for all nursing home admissions. The three most common ACSCs in our data—falls and trauma, pneumonia and bronchitis, and CHF—have also been reported to be among the top five conditions in other studies (Grabowski et al. 2007; McAndrew et al. 2015; Walker et al. 2009; Walsh et al. 2012; Xing et al. 2013). These common causes were also the most expensive, increasing the overall spending on ACSCs. Interestingly, dehydration, a prevalent problem in several US studies, was less prevalent in our data. This might be due to coding differences or different care practices regarding the handling of hydration in Swiss nursing homes.
We found that 40% of the costs of all hospitalizations for nursing home residents are potentially avoidable and given that the Swiss health-care system ranks above the US health-care system, this is concerning. However, it also suggests that some areas in health-care delivery could be improved. For example, falls can be prevented with measures minimizing fall risks (Walsh et al. 2012). As shown in a review, multifactorial interventions led by an interprofessional team are able to reduce both the number of fallers and recurrent fallers (Vlaeyen et al. 2015). One core problem in the management of falls in nursing homes is ruling out the diagnosis of fracture, since hardly any nursing homes have the infrastructure to run the diagnostic procedures necessary. An interesting development to counter this is mobile X-rays with telemedicine for nursing homes, which might change diagnostic procedures and reduce burdensome and costly transfers to the ED (Kjelle and Lysdahl 2017) due to the possibility of X-rays within nursing homes, reducing unnecessary ED admissions.
Staffing and skill mix is another central component to decreasing ambulatory care sensitive hospitalizations. The idea behind the development of ACSCs was that timely and effective access to ambulatory care could prevent hospitalizations (Bindman et al. 1995; Weissman et al. 1992). If residents at risk for conditions such as COPD or CHF were well monitored, some episodes of exacerbations might be avoided or detected early enough to be managed in the nursing home, although this does not apply for severe bronchospasm or hemodynamic instability for instance (Walsh et al. 2010). Similarly, early identification and treatment of pneumonia and bronchitis could prevent a hospital stay (Walsh et al. 2010). Early identification and timely intervention requires nursing home staff with the geriatric expertise able to recognize changes and act upon observations. Several studies from the USA show that the use of advanced practice nurses (APNs) reduces preventable hospitalizations (Bakerjian 2008; Kane et al. 2003; Ouslander et al. 2014; Rantz et al. 2015). These nurses with a master’s degree and training in extended clinical competencies are prepared to deliver care to vulnerable populations with complex health-care needs. In rural areas where shortages of primary care physicians are common, APNs are often the sole primary care provider for patients. Depending on US state legislature, APNs work independently or in collaboration with a physician. Within their specialty area, they assess, diagnose, and prescribe, managing the care of patients in its entirety, including referrals to physicians when indicated. In addition, they may also oversee other nursing home staff and provide training (Kane et al. 2003).
In the USA, the availability of a physician or APN for an on-site assessment of acute changes is considered a key strategy to reducing preventable hospitalizations (Ouslander et al. 2010). However, in Switzerland, access to a physician shows substantial regional variations. Patients living in regions with a high density of primary care physicians were less likely to be hospitalized due to an ACSC, whereas the risk was higher for patients living in rural areas (Berlin et al. 2014). Our results showing that more residents were admitted by ambulance for an ACSC (42%) than for non-ACSCs (31%), while it was the reverse for admission by a physician (ACSC: 46%, non-ACSC: 59%), may also reflect the issue of timely access to a primary care physician. Building a nursing home and primary care workforce with greater reliance on APNs, especially in rural areas where access to a primary care appointment may be delayed, could help reduce ACSC and associated costs in the Swiss health-care system.
Another important factor in reducing ACSCs is the implementation of advance care planning (ACP), which has been shown to increase the number of residents that die in the nursing home (Martin et al. 2016). ACP helps “ensure that people receive the medical care that is consistent with their values, goals and preferences during serious and chronic illness” (Sudore et al. 2017). This includes the appointment of a trusted person to make decisions on one’s behalf, when decision-making is no longer possible. Switzerland has recently introduced a national strategy for care planning, centered on the importance of long-term care. It outlines advance care planning and recommends discussing possible future developments and scenarios for the current illnesses, including ACSCs, to assess resident preferences and plan interventions in case of exacerbations (Bundesamt für Gesundheit und palliative ch 2018). Such care plans might also include physician orders about PRN (“as needed”) medications and documentation of wishes concerning treatment and hospitalization, which in turn supports care staff in managing acute situations when the physician is not immediately available, for example during nights and weekends.
Finally, it is important to note that programs taking a multifactorial approach have proven to be effective in reducing unnecessary hospitalizations. One such program is INTERACT, an intervention specifically designed to improve staff’s ability in early identification of complications, interprofessional communication, advance care planning, the effective treatment of chronic conditions, and timely reaction to acute changes in condition (Ouslander et al. 2014). Its effectiveness depends on the implementation of the INTERACT tools (e.g., tools to improve communication), which show the importance of the nursing homes’ motivation for change, since training and support alone will not reach the desired effect (Huckfeldt et al. 2018). Such programs are rare, and greater use should be explored to prevent hospitalizations in both the international and Swiss contexts.
The strength of the present study is the use of national data representing all Swiss hospitalizations, allowing us to provide a comprehensive description of nursing home hospitalizations. However, several limitations apply. First, the lists of conditions considered to be ambulatory care sensitive were developed in the USA and Canada and no corresponding structured expert rating was performed for the Swiss context. Although the main chronic conditions such as CHF, COPD, and pneumonia are at the forefront in ACSC lists, the inclusion of falls and trauma for nursing home residents may be controversial, since evidence for effective fall prevention is still scarce. Additionally, ACSCs provide a limited view on preventability and it is possible that not all ACSCs can be avoided in every case. In some instances, ACSCs might indicate a severe condition for which no early detection or advanced care planning could have avoided a hospitalization. Moreover, ACSCs do not take into account other system and patient level factors, such as treatment option availability in nursing homes, wishes of residents and relatives regarding hospitalizations, or residents’ overall health status. Thus, our findings on ACSCs provide valuable insight into preventable hospitalizations in Switzerland. Additional studies are needed to better understand the intricacies of different factors that favor hospitalizations.
In conclusion, hospitalizations due to ACSCs in Switzerland are frequent and costly. In order to reduce preventable hospitalizations, a multifaceted approach is needed. This should include addressing timely access to primary care with an increased use of APN roles in nursing homes; promotion of advance care planning; strengthening geriatric expertise of nursing home staff including monitoring of chronic diseases, the early detection and treatment of exacerbating symptoms, fall prevention, and the support of interprofessional communication, among other factors. The recommendation for financial reimbursement for ACP conversations at the Swiss policy level is a welcome development (Bundesamt für Gesundheit und palliative ch 2018).