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Preventable Hospitalizations

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Executive Summary

This Fact Book examines one critical area of health care quality: potentially preventable hospitalizations, or hospitalizations that may be preventable with high quality primary and preventive care. These hospitalizations may be avoided if clinicians effectively diagnose, treat, and educate patients, and if patients actively participate in their care and adopt healthy lifestyle behaviors. Thus, higher rates of "preventable hospitalizations" may pinpoint areas in which potential improvements can be made in the quality of the U.S. health care system.

This report presents information on preventable hospitalizations for select chronic and acute conditions, as well as for one birth outcome. The Fact Book first addresses these conditions in a broad, national-level context. It evaluates time trends between 1994 and 2000; variations across regions of the United States; and hospitalizations among priority populations, including children, older Americans, women, low-income, and rural residents. The report then provides detailed statistics for each health condition.

Results are based on the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database and the Agency for Healthcare Research and Quality's (AHRQ) Prevention Quality Indicators (PQIs). All statistics presented in this report are adjusted for the age and sex distribution of the population.

Decisionmakers at national, State, and local levels may use this Fact Book to establish national benchmarks and to identify target areas for quality improvement. For example, a community or State could apply the PQIs to hospital discharge data to identify regions with high numbers of preventable admissions for particular conditions.

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Have Admission Rates for Preventable Hospitalizations Changed Over Time?

Between 1994 and 2000, rates of preventable hospitalizations improved for certain health conditions. The most striking improvements were:

  • Hospital admission rates for treatment of angina without a procedure dropped 71 percent.
  • Hospitalizations for uncontrolled diabetes without complications declined nearly 30 percent.
  • Rates of hospitalization for adult asthma and pediatric gastroenteritis each decreased 20 percent.

In contrast, admission rates rose among other conditions as follows:

  • Chronic obstructive pulmonary disease increased by 20 percent.
  • Hypertension rose by 13 percent.
  • Bacterial pneumonia increased by 9 percent.

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Do Preventable Hospitalization Rates Vary Across the U.S.?

Variations in hospitalization rates exist across the 4 U.S. Census regions: Northeast, South, West, and Midwest. Admissions for preventable hospitalizations are most encouraging in the West, where rates are the lowest in the Nation for 15 of the 16 PQIs. The Northeast has the lowest rate of hospitalizations for perforated appendix.

Conversely, the South has the highest rates of hospitalization for most indicators, including:

  • Uncontrolled diabetes without complications and short-term diabetes complications.
  • Congestive heart failure and hypertension.
  • Chronic obstructive pulmonary disease.
  • Four acute conditions: bacterial pneumonia, dehydration, urinary tract infection, and pediatric gastroenteritis.
  • Low-weight births.

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Are Particular Age Groups More Likely to be Admitted to Preventable Hospitalizations?

Populations most vulnerable to illness, such as older Americans and very young children, experience the highest rates of preventable admission.

Older Americans are more likely than any other age group to be hospitalized for:

  • Congestive heart failure.
  • Chronic obstructive pulmonary disease.
  • Bacterial pneumonia.

Compared with children 5-17 years of age, young children under the age of 5 experience significantly higher rates of preventable hospitalization. The differences are most striking for:

  • Pediatric gastroenteritis.
  • Bacterial pneumonia.
  • Dehydration.

Also, young children under the age of 5 are much more likely to be hospitalized for pediatric asthma, the most common chronic disease among children.

These results indicate that specific age groups are more susceptible than others to certain conditions. Conditions such as congestive heart failure and chronic obstructive pulmonary disease are particularly relevant to older adults. Therefore, it may be appropriate to apply these prevention quality indicators to those who are 65 years of age and older. In contrast, PQIs for pediatric gastroenteritis, pediatric asthma, and dehydration are particularly useful for children, and can be used to examine the substantially higher risks observed for those who are 0-4 years of age.

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Are Preventable Hospitalization Rates Different for Men and Women?

The greatest difference occurs for treatment of adult asthma; for this condition, women are more than 2.5 times more likely than men to be admitted to the hospital. A contrast emerges for younger populations: girls are approximately 30 percent less likely than boys to be hospitalized for pediatric asthma.

Women also have higher rates of admission for:

  • Hypertension.
  • Dehydration.
  • Urinary tract infections.

On the other hand, women are less likely to be hospitalized for:

  • Long-term diabetes complications, including diabetes-related lower extremity amputations.
  • Congestive heart failure.
  • Angina without a procedure.
  • Bacterial pneumonia.
  • Perforated appendix.

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Is Community Income Related to Preventable Hospitalization Rates?

Residents from areas with the lowest median incomes (less than $25,000) have the highest rates of admission for all preventable hospitalizations. The greatest amount of variation occurs for:

  • Uncontrolled diabetes without complications and short-term diabetes complications.
  • Hypertension.
  • Adult asthma.

Disparities based on community incomes are more pronounced for chronic conditions than for acute conditions. Among the 10 chronic conditions, differences in admission rates between the lowest and highest income communities range from 76 to 278 percent. In contrast for the 5 acute conditions, differences in admission rates range from 6 to 78 percent.

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Do Admission Rates for Preventable Hospitalizations Differ Between Urban and Rural Residents?

In many cases, preventable admission rates are comparable for urban and rural residents. However, rural residents experience higher hospitalization rates for several conditions, including:

  • Uncontrolled diabetes without complications.
  • Hypertension.
  • Angina without a procedure.
  • Chronic obstructive pulmonary disease.
  • Bacterial pneumonia.
  • Dehydration.
  • Urinary tract infections.
  • Pediatric gastroenteritis.

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What Are the Patterns of Preventable Hospitalizations by Health Condition?

Table 1 summarizes the patterns of avoidable hospitalizations by types of conditions. The tables identify whether admission rates increased, decreased, or remained unchanged between 1994 and 2000, and also indicate the U.S. regions with the highest and lowest rates of hospitalization. In addition, the summary compares hospitalization rates for the following priority and reference populations:

  • Children: Very young children 0-4 years of age are compared with children 15-17 years.
  • Elderly: Individuals 65 years of age and older are compared with adults 18-44 years.
  • Women: Women are compared with men.
  • Low-income residents: Individuals from communities with the lowest median household incomes (<$25,000) are compared with residents from communities with median household incomes of $45,000 and above.
  • Rural residents: Individuals from rural areas are compared with urban dwellers.

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The mission of AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. To help fulfill this mission, AHRQ develops a number of databases, including those of the powerful Healthcare Cost and Utilization Project (HCUP). HCUP is a Federal-State-Industry partnership to build a standardized, multi-State health data system; HCUP features databases, software tools, and statistical reports to inform policymakers, health system leaders, researchers, and clinicians.

For data to be useful, they must be disseminated in a timely, accessible way. To meet this objective, AHRQ launched HCUPnet, an interactive, Internet-based tool for identifying, tracking, analyzing, and comparing statistics on hospital utilization, outcomes, and charges ( Menu-driven HCUPnet guides users in tailoring specific queries about hospital care online; with a click of a button, users receive answers within seconds.

In addition, AHRQ produces HCUP Fact Books to provide statistics about hospital care in the United States in an easy-to-use, readily accessible format. Each Fact Book presents information about specific aspects of hospital care—the single largest component of our health care dollar. The national estimates are benchmarks against which States can compare their own data. Previous Fact Books provided overviews on hospital stays in the U.S.; procedures performed in U.S. hospitals; and care for women, children, and adolescents.

This Fact Book addresses hospital admissions that may have been prevented through high quality primary and preventive care. The Nationwide Inpatient Sample (NIS) and the AHRQ Prevention Quality Indicators (PQIs) are used to evaluate trends over time, variations by U.S. geographic region, and differences among priority populations. The report also offers detailed statistics by specific health conditions.

We invite you to tell us how you are using this Fact Book and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please E-mail us at or send a letter to the address below:

Irene Fraser, Ph.D.
Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

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Without the following State Partners, the Healthcare Cost and Utilization Project and the 2000 Nationwide Inpatient Sample would not be possible:

  • Arizona Department of Health Services.
  • California Office of Statewide Health Planning & Development.
  • Colorado Health & Hospital Association.
  • Connecticut Chime, Inc.
  • Florida Agency for Health Care Administration.
  • Georgia GHA: An Association of Hospitals & Health Systems.
  • Hawaii Health Information Corporation.
  • Illinois Health Care Cost Containment Council.
  • Iowa Hospital Association.
  • Kansas Hospital Association.
  • Kentucky Department for Public Health.
  • Maine Health Data Organization.
  • Maryland Health Services Cost Review Commission.
  • Massachusetts Division of Health Care Finance and Policy.
  • Michigan Health & Hospital Association.i
  • Missouri Hospital Industry Data Institute.
  • New Jersey Department of Health and Senior Services.
  • New York State Department of Health.
  • North Carolina Department of Health and Human Services.
  • Oregon Association of Hospitals and Health Systems.
  • Pennsylvania Health Care Cost Containment Council.
  • South Carolina State Budget & Control Board.
  • Tennessee Hospital Association.
  • Texas Health Care Information Council.
  • Utah Department of Health.
  • Virginia Health Information.
  • Washington State Department of Health.
  • West Virginia Health Care Authority.
  • Wisconsin Department of Health and Family Services.

In May 2000, HCUP State Partners and AHRQ received the Secretary of Health and Human Services' Award for Distinguished Service for "leadership, teamwork, and creative thinking in increasing availability, utility, and value of data for policy makers and researchers concerned with hospital quality, utilization and cost."

i While this State Partner participated in HCUP during 2000, Michigan data were not included in the 2000 NIS. Thus, analyses conducted for this Fact Book are based on 2000 NIS data sampled from the other 28 State Partner databases.

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Thanks to Dian Zheng and Gail Eisen of Medstat for their assistance in statistical programming and editing, respectively, and also to The Madison Design Group for the design and layout of this Fact Book.

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Quality of care continues to be a focal point in current U.S. health care policy, as decisionmakers strive to improve the way the health care system meets the needs of the residents of the United States. This Fact Book offers insight into one critical area of health care quality—hospitalizations that may be preventable with high quality primary and preventive care. Such hospital admissions are commonly referred to as preventable hospitalizations.

Hospitalizations may be prevented when clinicians diagnose, educate, and treat patients in a timely and effective manner in outpatient settings, and when patients actively participate in their care and engage in healthy lifestyle behaviors. Thus, higher rates of "preventable hospitalizations" identify areas where potential improvements can be made in the quality of the U.S. health care system.

This Fact Book focuses on potentially preventable hospitalizations for select chronic and acute conditions, as well as one birth outcome. The chronic conditions are diabetes, including uncontrolled diabetes without complications, short-term and long-term diabetes complications, and diabetes-related lower-extremity amputations; circulatory diseases, such as congestive heart failure, hypertension, and angina without a procedure; and respiratory diseases, such as adult and pediatric asthma and chronic obstructive pulmonary disease. Acute conditions include pediatric gastroenteritis, bacterial pneumonia, dehydration, urinary tract infection, and perforated appendix. In addition, this Fact Book offers statistics on low-weight births.

Potentially preventable hospitalizations are a significant issue with regard to both quality and cost. During the year 2000, nearly 5 million admissions to U.S. hospitals involved treatment for 1 or more of these conditions; the resulting cost was more than $26.5 billion.1 While some hospitalizations were likely inevitable, many might have been prevented if individuals had received high quality primary and preventive care. Identifying and reducing such avoidable hospitalizations could help alleviate the economic burden placed on the U.S. health care system. Assuming an average cost of $5,300 per admission,1 even a 5 percent decrease in the rate of potentially avoidable hospitalizations could result in a cost savings of more than $1.3 billion.

The report first addresses these preventable hospitalizations in a broad, national context and examines 3 key issues: time trends between 1994 and 2000, variations among regions of the U.S., and hospitalizations among select priority populations.ii The report then presents detailed statistics for each health condition.

National policymakers may use the information in this Fact Book to evaluate priority areas and to identify targets for health care system improvement. State and local decisionmakers can use the national and regional trends as guides when planning quality improvement programs. Further, health care institutions, practitioners, and researchers may examine the national and regional benchmarks to establish health care evaluation standards and to determine areas that require more extensive study.

ii The Healthcare Research and Quality Act of 1999, the authorizing legislation for AHRQ, defines priority populations for AHRQ and includes children, elderly, women, minority, low-income, inner city, and rural residents, as well as individuals with special health care needs, including persons with disabilities or those requiring chronic or end-of-life care. Healthcare Research and Quality Act of 1999, Public Law 106-129, § 901, 113 Stat. 1654. This Fact Book does not include statistics based on minority status because national estimates for racial/ethnic subpopulations were not available. However, statistics by racial/ethnic subpopulations based on 16 States' data are available in the National Healthcare Disparities Report, developed by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (available online at

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How Are Potentially Preventable Hospitalizations Identified and How Do They Relate to Quality?

This report examines potentially preventable hospitalizations by using the AHRQ Prevention Quality Indicators (PQIs). The AHRQ PQIs examine quality by focusing on hospital admissions for ambulatory care sensitive conditions. These are health conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. Even though these indicators are based on hospital inpatient data, they provide insight into the quality of the health care system beyond the hospital setting. For example, individuals with diabetes may be hospitalized for diabetic complications if their conditions are not adequately monitored or if they do not receive the patient education needed for appropriate self-management. The PQIs are not definitive measures of quality; rather, they serve as screens for evaluating quality and for identifying areas that require more intensive study.

Table 2 lists the 16 AHRQ PQIs discussed in this Fact Book and identifies the age groups to which each PQI pertains. In addition, the Appendix offers information on how to obtain the PQI documentation and software.

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