Medical Discharges

Medical science provides clear guidelines about the need to hospitalize patients with some conditions. For patients with these conditions, the need for specific kinds of care determines what will be done, and the use of medical resources is not influenced by either the physician’s practice style or the per capita supply of hospital beds in the region. For example, patients with hip fractures are almost always hospitalized, because of the severity of their pain and the need for inpatient operative repair. Similarly, patients with newly diagnosed colorectal cancers are almost always hospitalized, because major bowel surgery is the universally accepted method of treating the disease.

But for many other conditions, medical science and theory are weak, and the rules of clinical practice are not nearly so clear. Many hospital admissions are for medical conditions – such as poorly controlled diabetes or worsening heart failure – which can be treated in either the inpatient or the outpatient setting, and for which hospitalization can often be prevented by better outpatient management. Although the same can be said for most medical causes of hospitalization, clinicians have identified a group of diagnoses referred to as “ambulatory care-sensitive” conditions. The variations among regions in admission rates of patients with these conditions can be ascribed to differences in clinical decision-making, rather than to differences in underlying illness rates. When science-based guidelines are weak, physicians must be guided by their subjective opinions about the effectiveness of admitting such patients to hospitals, rather than providing treatment in another setting. Hospitalization rates for these – and for most medical conditions – are also highly correlated with the local supply of hospital beds.

The counts of discharges (numerators) for medical conditions are determined from the Medicare Provider Analysis and Review (MedPAR) file. Medical discharges are identified using the Medicare diagnosis-related group (DRG) system. Specific ambulatory care-sensitive conditions were identified using International Classification of Disease (ICD-9-CM) diagnosis codes. Enrollee counts were obtained from the Medicare Denominator file. The Medicare enrollee population includes those alive and age 65 to age 99 on June 30 of the measurement year. Measures based on a count of fewer than 11 patients are not displayed for reasons of patient confidentiality. Rates with fewer than 26 expected events are also suppressed because of a lack of statistical precision. These cells are marked "na."


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The Dartmouth Atlas of Health Care is based at The Dartmouth Institute for Health Policy and Clinical Practice and is supported by a coalition of funders led by the Robert Wood Johnson Foundation, including the WellPoint Foundation, the United Health Foundation, the California HealthCare Foundation, and the Charles H. Hood Foundation.