title: The central role of comorbidity in predicting ambulatory care sensitive hospitalizations.
abstract: BACKGROUND
  Ambulatory care sensitive hospitalizations (ACSHs) are commonly used as measures of access to and quality of care. They are defined as hospitalizations for certain acute and chronic conditions; yet, they are most commonly used in analyses comparing different groups without adjustment for individual-level comorbidity. We present an exploration of their roles in predicting ACSHs for acute and chronic conditions.
  
  
  METHODS
  Using 1998-99 US Medicare claims for 1 06 930 SEER-Medicare control subjects and 1999 Area Resource File data, we modelled occurrence of acute and chronic ACSHs with logistic regression, examining effects of different predictors on model discriminatory power.
  
  
  RESULTS
  Flags for the presence of a few comorbid conditions-congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension and, for acute ACSHs, dementia-contributed virtually all of the discriminative ability for predicting ACSHs. C-statistics were up to 0.96 for models predicting chronic ACSHs and up to 0.87 for predicting acute ACSHs. C-statistics for models lacking comorbidity flags were lower, at best 0.73, for both acute and chronic ACSHs.
  
  
  CONCLUSIONS
  Comorbidity is far more important in predicting ACSH risk than any other factor, both for acute and chronic ACSHs. Imputations about quality and access should not be made from analyses that do not control for presence of important comorbid conditions. Acute and chronic ACSHs differ enough that they should be modelled separately. Unaggregated models restricted to persons with the relevant diagnoses are most appropriate for chronic ACSHs.
authors.affiliation: 1 Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.
authors.forename: Barry G
authors.initials: BG
authors.lastname: Saver
authors.forename: Ching-Yun
authors.initials: CY
authors.lastname: Wang
authors.forename: Sharon A
authors.initials: SA
authors.lastname: Dobie
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Green
authors.forename: Laura-Mae
authors.initials: LM
authors.lastname: Baldwin
mesh_terms: D000208:Acute Disease / Q000453:epidemiology; D000368:Aged; D000369:Aged, 80 and over; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D002908:Chronic Disease / Q000453:epidemiology; D015897:Comorbidity; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D016015:Logistic Models; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D015233:Models, Statistical; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
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