Currently Viewing:
The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
Kavita K. Patel, MD, MS
Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population
Maureen J. Lage, PhD
Authors’ Reply to “Comment on Generalizability of GLP-1 RA CVOTs in US T2D Population”
Eric T. Wittbrodt, PharmD, MPH; James M. Eudicone, MS, MBA; Kelly F. Bell, PharmD, MSPhr; Devin M. Enhoffer, PharmD; Keith Latham, PharmD; and Jennifer B. Green, MD
Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
Effect of Changing COPD Triple-Therapy Inhaler Combinations on COPD Symptoms
Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
Deaths Among Opioid Users: Impact of Potential Inappropriate Prescribing Practices
Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
Do Health Systems Respond to the Quality of Their Competitors?
Daniel J. Crespin, PhD; Jon B. Christianson, PhD; Jeffrey S. McCullough, PhD; and Michael D. Finch, PhD
Impact of Clinical Training on Recruiting Graduating Health Professionals
Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
Does Care Consultation Affect Use of VHA Versus Non-VHA Care?
Robert O. Morgan, PhD; Shweta Pathak, PhD, MPH; David M. Bass, PhD; Katherine S. Judge, PhD; Nancy L. Wilson, MSW; Catherine McCarthy; Jung Hyun Kim, PhD, MPH; and Mark E. Kunik, MD, MPH
Currently Reading
Continuity of Outpatient Care and Avoidable Hospitalization: A Systematic Review
Yu-Hsiang Kao, PhD; Wei-Ting Lin, PhD; Wan-Hsuan Chen, MPH; Shiao-Chi Wu, PhD; and Tung-Sung Tseng, DrPH

Continuity of Outpatient Care and Avoidable Hospitalization: A Systematic Review

Yu-Hsiang Kao, PhD; Wei-Ting Lin, PhD; Wan-Hsuan Chen, MPH; Shiao-Chi Wu, PhD; and Tung-Sung Tseng, DrPH
Higher continuity of care was statistically significant and was associated with fewer ambulatory care–sensitive condition hospitalizations.

Objectives: Continuity of care (COC) is a core element of primary care, which has been associated with improved health outcomes. Hospitalizations for ambulatory care–sensitive conditions (ACSCs) are potentially preventable if these conditions are managed well in the primary care setting. The aim of this article is to conduct a systematic review of literature on the association between COC and hospitalizations for ACSCs.

Study Design: Systematic literature review.

Methods: All published literature was searched for in PubMed and MEDLINE using PRISMA guidelines for collecting empirical studies. Studies published in English between 2008 and 2017 that measured the association between COC and at least 1 measure of ACSC hospitalizations were included in this review.

Results: A total of 15 studies met the inclusion criteria and applied claims data to examine the association between COC and ACSC hospitalizations. Most studies (93.3%) demonstrated a statistically significant association of higher COC in the outpatient setting with reduced likelihood of hospitalization for either all ACSCs or a specific ACSC. A strong association was observed among studies focusing on patients with a specific ACSC. Additionally, most studies used the Bice-Boxerman COC index to measure COC and measured COC before a period of measuring ACSC hospitalizations.

Conclusions: This systematic review identified that increased COC in outpatient care is associated with fewer hospitalizations for ACSCs. Increasing COC is favorable for patients who are managing a specific ACSC.

Am J Manag Care. 2019;25(4):e126-e134
Takeaway Points

This review analyzed findings using PRISMA guideline indicators to assess the association between continuity of care (COC) and hospitalization for ambulatory care–sensitive conditions (ACSCs).
  • Higher COC was statistically significantly associated with fewer ACSC hospitalizations and specific-ACSC hospitalizations.
  • The Bice-Boxerman COC index is most commonly used to measure COC in studies using claims data sets.
  • Most studies assessed COC before measuring ACSC hospitalizations.
An ambulatory care–sensitive condition (ACSC) is defined as a condition for which timely and effective primary care or outpatient care can potentially reduce the risk of subsequent hospitalization.1-4 Hence, a hospitalization for an ACSC is also called a preventable hospitalization or avoidable hospitalization.5,6 The Agency for Healthcare Research and Quality developed a set of Prevention Quality Indicators consisting of 16 ACSCs (eg, asthma, bacterial pneumonia, congestive heart failure, chronic obstructive pulmonary disease [COPD], dehydration, diabetes, hypertension, kidney/urinary tract infection, ruptured appendix) as indicators to measure the occurrence of potentially preventable hospitalizations and to track trends in hospitalizations for ACSCs to assess the quality of primary healthcare.7

In the United States, 1426 per 100,000 Americans were hospitalized for ACSCs in 2014, although the hospitalization rate for ACSCs has been decreasing slightly since 2005.8 Previous literature has found that patients with ACSC hospitalizations had higher expenditures than those without this type of hospital admission.9 Hence, hospitalizations due to ACSCs have become a critical discussion topic, because they not only reflect primary care quality1 but also relate to the cost consciousness10 in healthcare delivery systems. Additionally, ACSC hospitalizations have been used to measure the performance of primary care in healthcare systems around the world.7,11-13 Therefore, it is imperative to decrease the risk of ACSC hospitalizations for patients in the current healthcare system, in which costs of inpatient admissions are rapidly increasing.9,10

Continuity of care (COC), a core element of primary care,14,15 represents a constant curative relationship between a patient and a care provider that is characterized by trust and responsibility.16 Maintaining a continuous therapeutic relationship between patient and physician when treating chronic diseases has been proven to be associated with higher satisfaction, better compliance, and reduced hospitalizations and emergency department (ED) visits.17-21 Patients who have a stable connection with their healthcare providers for chronic disease treatment may improve their health outcomes because their providers are familiar with their disease conditions and understand their needs.21,22

Although studies have recognized COC as being positively associated with healthcare outcomes, the association between COC and all ACSCs (or a specific ACSC) is not well reviewed systematically. To our knowledge, there have been no review articles in this decade discussing the relationship between COC and ACSC hospitalizations. Therefore, this systematic review evaluated the association between COC and ACSC hospitalizations across studies published approximately in the past decade to provide a comprehensive, evidence-based perspective for clinicians and researchers who are interested in conducting research related to COC and ACSCs.


A systematic search of the PubMed and MEDLINE databases was conducted from January to February 2018 based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines23 (Figure 1). The initial search was limited to articles published in English from January 1, 2008, to December 31, 2017, that included COC in the title or abstract. After that, article titles or abstracts were reviewed to identify studies that included hospitalizations or admissions. Subsequently, combinations of terms relating to hospitalizations or admissions (ie, avoidable, preventable, and ambulatory care–sensitive conditions) were identified in the title or abstract. Article titles and abstracts were reviewed to assess whether the remaining articles met inclusion criteria, excluding studies and reports that had nonrelevant outcomes or that did not actually measure COC. Lastly, duplicates, books, reports, editorials, and review articles were removed. The remaining articles were assessed entirely and included in this review if criteria were met. We identified further relevant studies by searching the reference lists of included studies and using the Web of Science Core Collection to explore all potentially relevant research that cited the included studies.

A data extraction form was created to collect relevant study information from each article, including lead author name, year of publication, study design, number of study samples, age of the sample, and samples with or without a specific disease. Relevant information also included data resources, COC measurement, cutoff point for COC level, COC measuring period, healthcare outcomes measuring period, primary healthcare outcome(s) of interest, and significant results. Two researchers (Y.H.K. and W.T.L.) performed the initial search, conducted the appraisal of articles, extracted data from studies, and recorded findings in data extraction forms. Researchers summarized and synthesized these findings to evaluate inferences and conclusions made on the association between COC and ACSC hospitalizations across studies.

Figure 1 presents a diagrammatic flow of the process and search terms used to conduct the review. The search of PubMed and MEDLINE resulted in the identification of 3076 articles that mentioned COC. After applying exclusion criteria (ie, language was not English, title or abstract did not include “hospitalization[s]” or “admission[s]”), 482 articles remained. The titles of these articles were reviewed for relevance to outcomes of interest including “avoidable,” “preventable,” or “ACSC(s),” and 88 articles were retained. From the eligible articles, we excluded 50 duplicates, 3 reports or editorials, 2 review articles, and 20 articles that did not actually measure COC. Thus, 13 studies were selected.24-36 After manually hand searching the reference lists of included studies, 2 additional articles37,38 were selected for this review. Full articles from these 15 studies were then evaluated for inclusion. Summaries of these studies are presented in the Table24-38 [part A and part B]; an expanded version of the Table is in the eAppendix (available at

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up