Aim: Identify inpatient stays that are medically justified but might be avoided by optimal ambulatory care.

Cases: An ambulatory care sensitive condition (ACSC) corresponds to a justified hospital stay with one of the main diagnoses listed in Table A among eligible stays (see below):

Table A. List of main diagnoses sensitive to ambulatory care
Ambulatory care sensitive conditionsICD10 codesHierarchy   
ANEAnemiaD500, D508, D509, D510-D5293
ANGAnginaI200-I209, I240, I241, I248-I250, R072-R074, Z034, Z03519
ASTAsthmaJ450-J459, J464
CELCelluliteI891, J340, L010-L050, L080, L088, L089, L898, L98014
CORCongestive heart failureI110, I130, I132, I255, I500, J815
DENDental problemsA690, K046, K047, K121, K122, K1311
DESDehydrationK020, K040-A050, A052-A059, A072, A080-A085, K520-K522, K528, K5296
DIADiabetes with ketoacidosis or comaE100, E101, E110, E111, E120, E121, E130, E131, E1412
EPIEpilepsyG523, G400-G41915
GANGangreneR0216
GYNGynecological infectionN701, N709, N730-N7487
IMMImmunizing conditionsA35-A379, A800-A809, B050-B069, B161, B169, B180, B181, B260-B269, G000, J100-J1108
NUTNutritional deficiencyE40-E43, E550, E6439
ORLENT infectionH600-H602, H660-H664, J020-J040, J060-J069, J31210
PNEBacterial pneumoniaA481, A70, J13, J14, J153, J154, J157, J159-J168, J181-J18917
PULChronic obstructive pulmonary diseaseJ200-J209, J40-J449, J4718
PYEPyelonephritisN10-N12, N136, N15911
TENMalignant hypertensionI10, I11912
ULCPerforated or bleeding ulcerK226, K250-K252, K254-K256, K260-K262, K264-K266, K270-K272, K274-K276, K280-K282, K284-K296, K920-K92213

Eligible stays: Justified inpatient medical stays, corresponding to the following exclusion criteria:

• UNJUSTIFIED STAYS

• MORE OR LESS JUSTIFIED STAYS

• DAY SURGERY

• PROCEDURES justifying a hospitalization, except if related to an ACSC diagnosis: CRU4 for gangrene, OES2, PER2, STO2, STO3 for perforated or bleeding ulcer, OVA2, OVA3, PER2, UTE3, VAG2 for gynecological infections, PUL2 for bacterial pneumonia

• Birth at admission, transfer at discharge to hospital or nursing home, death

• academic missions (MISSIONS, CATEGORIES)

Output files: The results are provided globally in the AmbulatoryConditionsStays.xlsx Excel file. Detailed results are given per hospital stay in the Ambulatory_conditions.txt file, with the stay number and the corresponding main ambulatory care sensitive condition (as in table A), i.e., with the minimal hierarchy.

Interpretation: In principle, ACSCs detect situations that have deteriorated either because the patient did not have access to outpatient care early enough or because the treatment was not effective. For example, well-controlled diabetes or a gynecologic infection should not lead to hospitalization.

Strength of the indicator: There are many lists of ACSCs. Several of them include situations where hospitalization is not necessary (for uncomplicated diabetes, for example). Such ACSC rates then reflect the propensity to admit patients too easily to hospital rather than the quality of ambulatory care. The SQLape indicator excludes hospitalizations that are not clearly justified, guaranteeing better comparability. The algorithm was refined to limit the number of false positives and false negatives, in accordance with the recommendations in the article below:

Eggli Y, Desquins B, Seker E, Halfon P. Comparing potentially avoidable hospitalization rates related to ambulatory care sensitive conditions in Switzerland: the need to refine the definition of health conditions and to adjust for population health status. Health Services Research 2014, 14:25

Limitation: The indicator must be combined with insurance databases (e.g., bills) to understand if hospitalizations due to ACSC are related to lack of access to ambulatory care (frequently observed in the US) or to suboptimal outpatient care (more frequent in Switzerland for instance). However, it may be interesting for the hospital to analyze these situations to see in which areas better coordination with upstream ambulatory care could reduce the number of hospitalizations.