title: Factors associated with hospitalisations in chronic conditions deemed avoidable: ecological study in the Spanish healthcare system.
abstract: Potentially avoidable hospitalisations have been used as a proxy for primary care quality. We aimed to analyse the ecological association between contextual and systemic factors featured in the Spanish healthcare system and the variation in potentially avoidable hospitalisations for a number of chronic conditions.
  
  
  
  A cross-section ecological study based on the linkage of administrative data sources from virtually all healthcare areas (n=202) and autonomous communities (n=16) composing the Spanish National Health System was performed. Potentially avoidable hospitalisations in chronic conditions were defined using the Spanish validation of the Agency for Health Research and Quality (AHRQ) preventable quality indicators. Using 2012 data, the ecological association between potentially avoidable hospitalisations and factors featuring healthcare areas and autonomous communities was tested using multilevel negative binomial regression.
  
  
  
  In 2012, 151 468 admissions were flagged as potentially avoidable in Spain. After adjusting for differences in age, sex and burden of disease, the only variable associated with the outcome was hospitalisation intensity for any cause in previous years (incidence risk ratio 1.19 (95% CI 1.13 to 1.26)). The autonomous community of residence explained a negligible part of the residual unexplained variation (variance 0.01 (SE 0.008)). Primary care supply and activity did not show any association.
  
  
  
  The findings suggest that the variation in potentially avoidable hospitalisations in chronic conditions at the healthcare area level is a reflection of how intensively hospitals are used in a healthcare area for any cause, rather than of primary care characteristics. Whether other non-studied features at the healthcare area level or primary care level could explain the observed variation remains uncertain.
authors.affiliation: Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain.|Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Ester
authors.initials: E
authors.lastname: Angulo-Pueyo
authors.affiliation: Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain.|Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Ridao-López
authors.affiliation: Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain.|Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Natalia
authors.initials: N
authors.lastname: Martínez-Lizaga
authors.affiliation: Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain.|Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Sandra
authors.initials: S
authors.lastname: García-Armesto
authors.affiliation: Center for Public Health Research, Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), Valencia, Spain.
authors.forename: Salvador
authors.initials: S
authors.lastname: Peiró
authors.affiliation: Health Services and Policy Research Unit, Health Sciences Institute in Aragon (IACS) IIS Aragon, Zaragoza, Spain.|Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Spain.
authors.forename: Enrique
authors.initials: E
authors.lastname: Bernal-Delgado
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000145:classification*; D005260:Female; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010343:Patient Admission / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000592:standards* / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care; D012044:Regression Analysis; D013030:Spain
keywords: PRIMARY CARE