The patients’ perspective: what causes hospitalizations for ambulatory care sensitive conditions?

摘要

Introduction : In Portugal, the hospitalizations for ambulatory care sensitive conditions (ACSH) account for 12% of all hospitalizations with an estimated financial impact of up to 450 million€. Therefore, understanding the determinants of avoidable hospitalizations is important to develop policies and interventions that reduce the ACSH. Analyzing the patient’s perspective brings an angle relevant to explain the ACSH. Despite patients are the most qualified to express the social and individual context of their experience, few studies have investigated the patients’ perspective about what causes ACSH. The aim of this study is to compare the perspective of patients on the determinants of the ACSH. Methods : A literature review was performed to map the determinants of the ACSH, by adapting the work of Sentell et al. (2016). The map takes into account 8 domains, namely healthcare access, disease self-management, individual characteristics, environmental characteristics, health status, lifestyle, health literacy and social support. Each domain gathers a set of determinants of the ACSH. This framework was used to analyze the patients’ perspective through the point of view of the individual patient and the patient’s association representatives. Semi-structured interviews were conducted to the representatives (n=6) and to the patients with an ACSH at the Internal Medicine Wards of Central Lisbon University Hospital Center (n=22). The content of the interviews was coded according to the previously mentioned map. Results : Determinants regarding the causes of the ASCH were mentioned differently according to the two perspectives. On the patient’s interviews, the domain health status (determinant: multiple chronic diseases) was mention on 18% of the interviews and the domains disease self-management (determinant: incapacity to self-manage disease) and access to healthcare (determinant: poor coordination across levels of care) were mention on 10% of the interviews. The domain access to healthcare (determinants: poor coordination across levels of care, inadequacy of healthcare services and relation between patient and health professional) was mention on 28% of the representative’s interviews. Discussion : Different determinants are emphasized when considered patient’s or patient’s representatives perspectives, both relate to complexity and fragmentation of the health care system. Each chronic disease demands a growing number of interventions, providers and settings of care multiplied for each single disease results in serious difficulties for patients. In order to be effective, an integrated care solution needs to be drawn taking into account the patient background. Conclusions : On the analysis of the patient’s perspective, we found different information from the one we usually get on traditional databases. It also exposes the disagreement between the two patients’ perspectives which confirms the need to promote patient-centered care and integrated healthcare delivery in order to minimize the ACSH. Limitations : The ongoing study and the single setting of the interviews are recognized limitations of our analysis. Suggestions for future research : Based on this evidence, we will apply a patient survey to identify the most important determinants of the ACSH to a wider sample (approximately 200 individuals). Funding acknowledgment :The Government of Kazakhstan through the WHO European Centre for Primary Health Care, Almaty.