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Preventable

Hospitalizations: 

Window Into Primary and

Preventive Care, 2000

Preventable

Hospitalizations: 

Window Into Primary and

Preventive Care, 2000
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HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

i

Preventable

Hospitalizations: 

indow Into Primary and

reventive Care, 2000

Preventable

Hospitalizations: 

indow Into Primary and

reventive Care, 2000

Denise T. Kruzikas, Ph.D. ■ H. Joanna Jiang, Ph.D. ■ Denise Remus, Ph.D., R.N.

Marguerite L. Barrett, M.S. ■ Rosanna M. Coffey, Ph.D. ■ Roxanne Andrews, Ph.D.

FACTS ON: ■ TRENDS OVER TIME■ VARIATIONS ACROSS U.S. REGIONS■ PRIORITY POPULATIONS■ CHRONIC CONDITIONS■ ACUTE CONDITIONS■ BIRTH OUTCOMES
ed Citation

emus D, Barrett ML, Coffey RM, Andrews R.

ns: A Window Into Primary and Preventive

ealthcare Research and Quality, 2004.

AHRQ Publication No. 04-0056.

edgments

nd Gail Eisen of Medstat for their assistance in

and editing, respectively, and also to The

or the design and layout of this Fact Book.

ct Book Series

e United States, 1997 

0031) 

ospitals, 1997 (AHRQ Pub. No. 01-0016)

S. Hospitals, 2000 

0044)

 Adolescents in U.S. Hospitals, 2000 

0004)

izations: A Window Into Primary and

0 (AHRQ Pub. No. 04-0056)

UP Fact Books are available online

ta/hcup/datahcup.htm#Recent) and from the

ringhouse. To order by telephone, please call

title and publication number.

ffey are from Medstat, Washington, DC. H. Joanna Jiang, Denise Remus,

ncy for Healthcare Research and Quality, Rockville, MD. Marguerite L.

ndria, Virginia.
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Summary

iii

Summary

ne critical area of health care quality: 

ospitalizations, or hospitalizations that

h quality primary and preventive care.

e avoided if clinicians effectively diagnose,

nd if patients actively participate in their

yle behaviors. Thus, higher rates of

” may pinpoint areas in which potential

n the quality of the U.S. health care system.

on on preventable hospitalizations for

tions, as well as for one birth outcome.

these conditions in a broad, national-level

ds between 1994 and 2000; variations across

and hospitalizations among priority

en, older Americans, women, low-income,

rt then provides detailed statistics for each

ased on the Healthcare Cost and Utilization

Inpatient Sample (NIS) database and the

rch and Quality’s (AHRQ) Prevention

ll statistics presented in this report are

distribution of the population.

tate, and local levels may use this Fact

nchmarks and to identify target areas for

mple, a community or State could apply

ge data to identify regions with high

issions for particular conditions.

S FOR PREVENTABLE

NGED OVER TIME?

 of preventable hospitalizations improved

The most striking improvements were:

■ Hospital admission rates for treatment of angina without a

procedure dropped 71 percent.

■ Hospitalizations for uncontrolled diabetes without complications

declined nearly 30 percent.

■ Rates of hospitalization for adult asthma and pediatric

gastroenteritis each decreased 20 percent.

In contrast, admission rates rose among other conditions as follows:

■ Chronic obstructive pulmonary disease increased by 20 percent.■ Hypertension rose by 13 percent.■ Bacterial pneumonia increased by 9 percent.DO PREVENTABLE HOSPITALIZATION RATES VARY ACROSS THE U.S.?Variations in hospitalization rates exist across the 4 U.S. Census regions:Northeast, South, West, and Midwest. Admissions for preventablehospitalizations are most encouraging in the West, where rates are thelowest in the Nation for 15 of the 16 PQIs. The Northeast has the lowestrate of hospitalizations for perforated appendix.Conversely, the South has the highest rates of hospitalization for mostindicators, including:■ Uncontrolled diabetes without complications and short-term

diabetes complications

■ Congestive heart failure and hypertension■ Chronic obstructive pulmonary disease
s: bacterial pneumonia, dehydration, urinary

ediatric gastroenteritis

GE GROUPS MORE LIKELY TO BE

NTABLE HOSPITALIZATIONS?

able to illness, such as older Americans and

perience the highest rates of preventable

re likely than any other age group to be

ure

pulmonary disease

 

 5–17 years of age, young children under 

significantly higher rates of preventable

rences are most striking for:

itis

er the age of 5 are much more likely to be

 asthma, the most common chronic disease

t specific age groups are more susceptible than

ns. Conditions such as congestive heart failure

and chronic obstructive pulmonary disease are particularly relevant toolder adults. Therefore, it may be appropriate to apply these preventionquality indicators to those who are 65 years of age and older. In contrast,PQIs for pediatric gastroenteritis, pediatric asthma, and dehydration areparticularly useful for children, and can be used to examine thesubstantially higher risks observed for those who are 0–4 years of age.

ARE PREVENTABLE HOSPITALIZATION RATES DIFFERENT FOR MEN AND WOMEN?The greatest difference occurs for treatment of adult asthma; for thiscondition, women are more than 2.5 times more likely than mento be admitted to the hospital. A contrast emerges for youngerpopulations: girls are approximately 30 percent less likely than boysto be hospitalized for pediatric asthma.Women also have higher rates of admission for:■ Hypertension■ Dehydration■ Urinary tract infections

On the other hand, women are less likely to be hospitalized for:

■ Long-term diabetes complications, including diabetes-related lower

extremity amputations

■ Congestive heart failure■ Angina without a procedure■ Bacterial pneumonia■ Perforated appendix
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Summary

v

■ Bacterial pneumonia■ Dehydration■ Urinary tract infections■ Pediatric gastroenteritisWHAT ARE THE PATTERNS OF PREVENTABLEHOSPITALIZATIONS BY HEALTH CONDITION? The following tables summarize the patterns of avoidable hospitalizationsby types of conditions. The tables identify whether admission ratesincreased, decreased, or remained unchanged between 1994 and 2000,and also indicate the U.S. regions with the highest and lowest rates ofhospitalization. In addition, the summary compares hospitalization ratesfor the following priority and reference populations:■ Children: Very young children 0–4 years of age are compared with

children 15–17 years.

■ Elderly: Individuals 65 years of age and older are compared with

adults 18–44 years.

■ Women: Women are compared with men.■ Low-income residents: Individuals from communities with the

lowest median household incomes (<$25,000) are compared withresidents from communities with median household incomes of$45,000 and above.

■ Rural residents: Individuals from rural areas are compared with

urban dwellers.

 RELATED TO PREVENTABLE

S?

e lowest median incomes (less than

es of admission for all preventable

 amount of variation occurs for:

thout complications and short-term

nity incomes are more pronounced for

cute conditions. Among the 10 chronic

mission rates between the lowest and

range from 76 to 278 percent. In contrast,

fferences in admission rates range from 6

OR PREVENTABLE

FER BETWEEN URBAN AND 

dmission rates are comparable for urban 

, rural residents experience higher

al conditions, including:

thout complications

ure

monary disease
able Hospitalizations by Types of Conditions

REGIONAL VARIATION VARIATION BY PRIORITY POPULATION

CHANGES Low-Income

OVER TIME Region with Region with Children Elderly Residents Rural

(1994–2000) Highest Rates Lowest Rates (0–4 years) (≥65 years) Women (<$25,000) Residents

mplications Decreased South West n/a + No difference + +

Increased South West n/a - No difference + No difference

No change Northeast West n/a + No difference + No difference

amputations No change Northeast West n/a + - + No difference

No change South West n/a + - + No difference

Increased South West n/a ++++

Decreased Northeast West n/a + - + +

Decreased Northeast West n/a + + + No difference

No change Northeast West + n/a - + No difference

ease Increased South West n/a + No difference + +

hildren 0–4 years of age are compared with children 15–17 years.

years of age and older are compared with adults 18–44 years.

ompared with men.

Individuals from communities with the lowest median household incomes (<$25,000) are compared with residents from communities

d incomes of $45,000 and above.

duals from rural areas are compared with urban dwellers.

higher for the priority population compared with the reference group (significant at p≤0.05).

ower for the priority population compared with the reference group (significant at p≤0.05).

ates increased over time (significant at p≤0.05).

ates decreased over time (significant at p≤0.05).

on rates are comparable between the priority population and the reference group.

Quality Indicator are provided in the Glossary section of this report.
 Hospitalizations by Types of Conditions

REGIONAL VARIATION VARIATION BY PRIORITY POPULATION

CHANGES Low-Income

OVER TIME Region with Region with Children Elderly Residents Rural

(1994–2000) Highest Rates Lowest Rates (0–4 Years) (≥65 years) Women (<$25,000) Residents

Increased South West n/a + - + +

No change South West n/a + + + +

No change South West n/a + + + +

Decreased Midwest Northeast n/a + - + No difference

Decreased South West + n/a No difference + +

No change South West n/a n/a No difference + No difference

en 0–4 years of age are compared with children 15–17 years.

s of age and older are compared with adults 18–44 years.

red with men.

viduals from communities with the lowest median household incomes (<$25,000) are compared with residents from communities

omes of $45,000 and above.

from rural areas are compared with urban dwellers.

for the priority population compared with the reference group (significant at p≤0.05).

or the priority population compared with the reference group (significant at p≤0.05).

creased over time (significant at p≤0.05).

ecreased over time (significant at p≤0.05).

s are comparable between the priority population and the reference group.

Indicator are provided in the Glossary section of this report.

HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Summary

vii

HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

1

Table of Contents

ontents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4PART I. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Trends over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Variations Across U.S. Regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Differences Among Priority Populations* . . . . . . . . . . . . . . . . . . . . 14

Children and Older Americans . . . . . . . . . . . . . . . . . . . . . . . . . 14Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Low-Income Community Residents . . . . . . . . . . . . . . . . . . . . . 18Rural Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

PART II. Detailed Statistics by Health Condition . . . . . . . . . . . . . . . . . . 23

Chronic Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Diabetes** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Circulatory Diseases** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Respiratory Diseases** . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Acute Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Birth Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Appendix: AHRQ Prevention Quality Indicators . . . . . . . . . . . . . . . . . . 44Source of Data for This Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

*The Healthcare Research and Quality Act of 1999, the re-authorizing legislation for AHRQ, identifies prioritypopulations to be included in research, evaluations, and demonstration projects (Healthcare Research and Quality Act of 1999, Public Law 106-129, § 901, 113 Stat. 1654).**These conditions are related to the priority areas identified by the Institute of Medicine for improving the health of the U.S. population (Institute of Medicine. 2003. Priority Areas for National Action: Transforming Health Care Quality. Washington, DC: National Academies Press).
d

ncy for Healthcare Research and Quality 

 the quality, safety, efficiency, and effectiveness

ericans. To help fulfill this mission, AHRQ

tabases, including those of the powerful

zation Project (HCUP). HCUP is a Federal

p to build a standardized, multi-State health

res databases, software tools, and statistical

makers, health system leaders, researchers,

hey must be disseminated in a timely,

his objective, AHRQ launched HCUPnet, an

ed tool for identifying, tracking, analyzing,

 on hospital utilization, outcomes, and 

q.gov/HCUPnet.asp). Menu-driven HCUPnet

pecific queries about hospital care online; with

receive answers within seconds.

uces the HCUP Fact Books to provide statistics

e United States in an easy-to-use, readily

act Book presents information about specific

— the single largest component of our health

estimates are benchmarks against which States

ata. Previous Fact Books provided overviews

.S.; procedures performed in U.S. hospitals;

dren, and adolescents.

s hospital admissions that may have been

 quality primary and preventive care. The

ample (NIS) and the AHRQ Prevention

s) are used to evaluate trends over time,

phic region, and differences among priority

 also offers detailed statistics by specific 

We invite you to tell us how you are using this Fact Book and otherHCUP data and tools, and to share suggestions on how HCUP productsmight be enhanced to further meet your needs. Please e-mail us athcup@ahrq.gov or send a letter to the address below.

Irene Fraser, Ph.D.DirectorCenter for Delivery, Organization, and MarketsAgency for Healthcare Research and Quality540 Gaither RoadRockville, MD 20850
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

3

Alabama

Arizona Arkansas

California Colorado

Connecticut

Delaware

Florida

Georgia

Idaho

Illinois Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nevada Nebraska

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North

Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South

Carolina

South

Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West

Virginia

Wisconsin

Wyoming

Hawaii

Alaska

Contributors

* Utah Department of Health* Virginia Health Information* Washington State Department of Health* West Virginia Health Care Authority* Wisconsin Department of Health and Family Services

In May 2000, HCUP State Partners and AHRQ received the Secretary of Health and Human Services’ Award for Distinguished Service for“leadership, teamwork, and creative thinking in increasing availability,utility, and value of data for policy makers and researchers concernedwith hospital quality, utilization and cost.”

i While this State Partner participated in HCUP during 2000, Michigan data were not included in the 2000 NIS.

Thus, analyses conducted for this Fact Book are based on 2000 NIS data sampled from the other 28 StatePartner databases.

ors

te 

 Cost 

he

ample

h Services

e 

ment

re Administration

 of 

s 

orporation

ntainment Council

blic Health 

tion

st Review 

ealth Care Finance and Policy

Associationi

ata Institute

ealth and Senior Services

of Health

of Health and Human Services

tals and Health Systems

st Containment Council

t & Control Board

ion

n Council
tion

es to be a focal point in current U.S. health 

n makers strive to improve the way the health

eds of the residents of the United States. This

nto one critical area of health care quality —

 be preventable with high quality primary and

pital admissions are commonly referred to as

ons.

prevented when clinicians diagnose, educate,

mely and effective manner in outpatient

ts actively participate in their care and engage

viors. Thus, higher rates of “preventable

areas where potential improvements can be

e U.S. health care system.

n potentially preventable hospitalizations 

ute conditions, as well as one birth outcome.

re diabetes, including uncontrolled diabetes

short-term and long-term diabetes

etes-related lower-extremity amputations;

h as congestive heart failure, hypertension,

ocedure; and respiratory diseases, such as 

ma and chronic obstructive pulmonary disease.

 pediatric gastroenteritis, bacterial pneumonia,

ct infection, and perforated appendix. In

offers statistics on low-weight births.

ospitalizations are a significant issue with 

d cost. During the year 2000, nearly 5 million

als involved treatment for 1 or more of these

cost was more than $26.5 billion.1 While some

ly inevitable, many might have been prevented

d high quality primary and preventive care.

 such avoidable hospitalizations could help

urden placed on the U.S. health care system.

Assuming an average cost of $5,300 per admission,1 even a 5 percent

decrease in the rate of potentially avoidable hospitalizations could resultin a cost savings of more than $1.3 billion.The report first addresses these preventable hospitalizations in a broad,national context and examines 3 key issues: time trends between 1994and 2000, variations among regions of the U.S., and hospitalizationsamong select priority populations.ii The report then presents detailed

statistics for each health condition.National policymakers may use the information in this Fact Book to evaluate priority areas and to identify targets for health care systemimprovement. State and local decisionmakers can use the national and regional trends as guides when planning quality improvementprograms. Further, health care institutions, practitioners, andresearchers may examine the national and regional benchmarks toestablish health care evaluation standards and to determine areas thatrequire more extensive study.

ii The Healthcare Research and Quality Act of 1999, the authorizing legislation for AHRQ, defines priority

populations for AHRQ and includes children, elderly, women, minority, low-income, inner city, and ruralresidents, as well as individuals with special health care needs, including persons with disabilities or thoserequiring chronic or end-of-life care. Healthcare Research and Quality Act of 1999, Public Law 106-129, § 901,113 Stat. 1654. This Fact Book does not include statistics based on minority status because national estimatesfor racial/ethnic subpopulations were not available. However, statistics by racial/ethnic subpopulations basedon 16 States’ data are available in the National Healthcare Disparities Report, developed by the Agency forHealthcare Research and Quality, U.S. Department of Health and Human Services (available online athttp://www.qualitytools.ahrq.gov/disparitiesreport/download_report.aspx).
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

5

Introduction

 PREVENTABLE HOSPITALIZATIONS

DO THEY RELATE TO QUALITY?

ally preventable hospitalizations by using

y Indicators. The AHRQ PQIs examine

al admissions for ambulatory care sensitive

conditions for which good outpatient care

eed for hospitalization, or for which early

plications or more severe disease. Even

based on hospital inpatient data, they

ity of the health care system beyond the

hospital setting. For example, individuals with diabetes may behospitalized for diabetic complications if their conditions are notadequately monitored or if they do not receive the patient educationneeded for appropriate self-management. The PQIs are not definitivemeasures of quality; rather, they serve as screens for evaluating qualityand for identifying areas that require more intensive study.The table below lists the 16 AHRQ PQIs discussed in this Fact Bookand identifies the age groups to which each PQI pertains. In addition,the Appendix offers information on how to obtain the PQIdocumentation and software.

AGE GROUPS 

0–17 years 18–44 years 45–64 years 65 years and older

tions X XX

X XXX XX

ations X XX

X XXX XXX XXX XXX XX

XXX X XXX X XXX X XXX X XX

neonates

ator are provided in the Glossary section of this report.

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PART I:

Overview

PART I:

Overview
mission rates

entable

zations

 over time?

Between 1994 and 2000, rates of hospital admission improved for particularhealth conditions. Some of the most striking improvements were:■ Hospital admission rates for treatment of angina without a

procedure dropped 71 percent during the 6-year period.

■ Admission rates for uncontrolled diabetes without complications

declined nearly 30 percent.

■ Rates of hospitalization for adult asthma and pediatric

gastroenteritis decreased 20 percent.

These reductions may be attributed to a number of factors, includingincreased patient education, enhanced awareness and access to healthcare hotlines, better environmental settings, and changes in medicaltechnologies. In addition, lower admission rates may indicate that thequality of primary and preventive care improved for these conditionsduring this time period.At the same time, opportunities for improvement exist. Specialattention should be directed to conditions for which admission ratesincreased over time. For example, between 1994 and 2000, rates ofhospitalization increased as follows:

■ Chronic obstructive pulmonary disease rose by 20 percent.■ Hypertension increased by 13 percent.■ Bacterial pneumonia rose by 9 percent.

Older Americans are at highest risk of hospitalization for these 3conditions. More needs to be learned about the reasons for theobserved increases so that decisionmakers can work towardeliminating unnecessary hospitalizations.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Trends Over Time

9

ions for which hospitalization rates did 

me. Although it is encouraging that the

o reduce the need for hospitalization for

ctively managed outside the hospital.

pplied to prevent unnecessary admissions 

: long-term diabetes complications,

mity amputations, congestive heart 

tract infection, and low-weight births.

ADMISSION RATE TREND

BETWEEN 1994 AND 2000 

DECREASE* NO CHANGE INCREASE*

tions X

X

X

ations X

X

X

X

X

ADMISSION RATE TREND

BETWEEN 1994 AND 2000 

PREVENTION QUALITY INDICATOR† DECREASE* NO CHANGE INCREASE*Pediatric asthma XChronic obstructive pulmonary disease XPediatric gastroenteritis XBacterial pneumonia XDehydration XUrinary tract infection XPerforated appendix XLow-weight births X

on Rates for Preventable Conditions

Indicator are provided in the Glossary section of this report.

ned at p≤0.05.
s

ntable

zation rates

oss the U.S.?

SE GRAPHS?

e preventable hospitalization rates of 3 regions

dwest) to the rates of 1 common region, the

 graphs, each PQI admission rate for the

t is divided by the PQI admission rate 

d, the Northeast admission rate compared to

s with rates higher than those in the Northeast

eference point, 1.00, while regions with lower

ot reach the 1.00 line. The graphs also display

ference in hospitalization rates between 

he Northeast. For example, compared with 

 rates for uncontrolled diabetes without

ent higher in the South and 48 percent lower

x100=18%; [1.00–0.52]x100=48%). All rates

ex, using year 2000 as the standard

Variations in hospitalization rates exist across the 4 U.S. Censusregions: Northeast, South, West, and Midwest. The greatest amount ofvariation occurs for 3 chronic conditions — uncontrolled diabeteswithout complications, hypertension, and chronic obstructivepulmonary disease.Admissions for preventable hospitalizations are most encouraging inthe West, where rates are the lowest in the nation for 15 of the 16 PQIs.

Conversely, the South has the highest rates of hospitalization for mostindicators, including:

■ Uncontrolled diabetes without complications■ Short-term diabetes complications■ Congestive heart failure■ Hypertension■ Chronic obstructive pulmonary disease■ Four acute conditions: bacterial pneumonia, dehydration, urinary

tract infections, and pediatric gastroenteritis

■ Low-weight births 

For these conditions, the differences in admission rates between theSouth and the Northeast (the common reference group used in the graph) range from 10 percent for congestive heart failure and low-weight births to 36 percent for urinary tract infections.The low rates of admission observed in some areas of the countryindicate the potential for improvement for other regions, and moreresearch is needed to identify how the health care system can effectivelyreduce unnecessary hospitalizations.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Variations Across U.S. Regions

11
s
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Variations Across U.S. Regions

13
opulationsiii

cular

ps more 

 be admitted

entable

zations?

able to illness, such as older Americans and

erience the highest rates of admission. Older

y than any other age group to be hospitalized,

ure

pulmonary disease

mong this population may be appropriate

tend to be more frail and suffer from more

mericans. On the other hand, some admissions

ugh better management of chronic conditions

the disease and more effective treatment upon

.

The PQIs for congestive heart failure and chronic obstructivepulmonary disease are particularly relevant to older Americans, as thispopulation is at substantially higher risk of hospitalization for theseconditions. As a result, it may be appropriate to apply these preventionquality indicators specifically to individuals 65 years of age and older.Certain pediatric groups are also more likely to be admitted to U.S. hospitals.

In fact, very young children under the age of 5 years have dramaticallyhigher rates of hospitalization than older children. The differences betweenpediatric groups are most striking in relation to the treatment of:

■ Pediatric gastroenteritis■ Bacterial pneumonia■ Dehydration

For these 3 conditions, admission rates for children 0–4 years of age areup to 13 times higher than the admission rates for older children.

In addition, children 0–4 years of age are much more likely than their oldercounterparts to be hospitalized for asthma, the most common chronicdisease among children. Clinicians may be more cautious when treating this age group, which could result in a lower threshold for hospitalization.While such preferences may be appropriate given the increased vulnerabilityof this patient population, many admissions may be preventable. Morework needs to be done to ensure that very young children obtain high

quality primary and preventive care and are hospitalized only when necessary.

The underlying causes of disease and reasons for hospitalization likely vary between age groups. For example, gastroenteritis and dehydrationamong children may be related to environmental and living conditions,whereas these same conditions among older populations may be attributedto other factors. Therefore, it is important to consider such differenceswhen examining the prevention quality indicators across age groups.iii The Healthcare Research and Quality Act of 1999, the re-authorizing legislation for AHRQ, identifies priority

populations to be included in research, evaluations, and demonstration projects (Healthcare Research andQuality Act of 1999, Public Law 106-129, § 901, 113 Stat. 1654).
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

15

Differences Among Priority Populations

AGE GROUP 

18–44 (a) 45–64 65 

YEARS YEARS YEARS

tions 15 36* 59*

54 49* 45*

33 158* 339*

ations 5 55* 140*

35 355* 2,321*

15 57* 116*

12 90* 197*

AGE GROUP 

18–44 (a) 45–64 65 

PREVENTION QUALITY INDICATOR† YEARS YEARS YEARSAdult asthma 89 131* 158*Chronic obstructive pulmonary disease 20 272* 1,138*Bacterial pneumonia 92 323* 1,815*Dehydration 32 90* 568*Urinary tract infections 64 97* 647*Perforated appendix 230 443* 579*

ventable Conditions per 100,000 Population 18 Years and Older, 2000ventable Conditions per 100,000 Population Less than 18 Years, 2000

AGE GROUP 

0–4 (a) YEARS 5–9 YEARS 10–14 YEARS 15–17 YEARS

400 179* 113* 70*

465 104* 42* 35*

333 62* 24* 27*

148 39* 20* 51*

598 356* 285* 233*

302 54* 30* 27*

ndicator are provided in the Glossary section of this report.

≤0.05. Rates are adjusted by age and sex, using year 2000 as the standard population.

Indicator are provided in the Glossary section of this report.

≤0.05. Rates are adjusted by age and sex, using year 2000 as the standard population.
opulations

lect conditions vary by patient gender. Women

dmission for 4 conditions:

ns

entable

zation 

ferent 

and women?

The most striking difference occurs for treatment of adult asthma;for this condition, women are more than 2.5 times more likely thanmen to be admitted to the hospital. This relationship presents a sharpcontrast to that observed for pediatric asthma. Among children, girlsare approximately 30 percent less likely than boys to be hospitalized for asthma.On the other hand, women are less likely to be hospitalized for anumber of other conditions, including:■ Long-term diabetes complications■ Diabetes-related lower extremity amputations■ Congestive heart failure■ Angina without a procedure■ Bacterial pneumonia■ Perforated appendix

Of these conditions, the gender difference is most dramatic for diabetes-related lower extremity amputations. Hospitalizationsinvolving treatment for this condition are approximately 50 percentlower for women than for men. Again, the causes for this difference areuncertain and more research is needed to better understand why menmay be at higher risk for hospital admission.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

17

Differences Among Priority Populations
opulations

unity income

o preventable

zation rates?

The likelihood of hospitalization increases dramatically as mediancommunity income decreases. Residents from areas with the lowestmedian incomes (<$25,000) have the highest rates of admission forevery preventable hospitalization indicator. When comparingcommunities with the lowest incomes to those with the highestincomes, differences in admission rates range from 5 to 74 percent.The greatest amount of variation between the lowest and highestincome areas occurs for treatment of:■ Uncontrolled diabetes without complications■ Hypertension■ Short-term diabetes complications■ Adult asthma

Community income disparities are less pronounced for treatment of acute conditions than for chronic conditions. For the 5 acuteconditions, admission rates are 6 to 78 percent higher amongindividuals from the lowest income communities, as compared withresidents from areas with median incomes of $45,000 or more.In contrast, rates of hospitalization vary considerably for treatment of the 10 chronic conditions. Among these conditions, differences inadmission rates range from 76 to 278 percent between the lowest andhighest income communities. For 9 of these conditions, admission ratesare at least 2 times higher among lowest income residents, as comparedwith residents of the highest income areas.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

19

Differences Among Priority Populations
opulations
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

21

Differences Among Priority Populations

ain conditions vary by location of patient

occur, rural residents are consistently at

d to the hospital.

parable between urban and rural residents

ions. However, rural residents are more

ospital for:

thout complications

ure

monary disease

ion rates 

table

s differ

urban and rural

?

More room for improvement exists among the acute conditions.Rural residents have higher rates of admission for almost every acutecondition, including:■ Bacterial pneumonia■ Dehydration■ Urinary tract infections■ Pediatric gastroenteritis

The sole exception among acute conditions is perforated appendix,where the likelihood of admission is similar for urban and rural dwellers.Rural residents may consistently have higher rates of hospitalization foracute conditions because of difficulty in accessing care. For example,compared with urban residents, rural residents may have feweralternatives to hospital treatment. It is also possible that individualcare-seeking behaviors and admission thresholds may differ betweenurban and rural populations. In addition, environmental factors thatincrease an individual’s susceptibility to particular conditions may varybetween urban and rural areas.In recent years, decisionmakers and researchers have placed increasedattention on the health and availability of high quality care for ruralAmericans. As more information becomes available, health care leadersmay be able to identify and address the potential disparitiesexperienced by this population.
opulations
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PART II:

Detailed Statistics by

Health Condition

PART II:

Detailed Statistics by

Health Condition
S:

Diabetes 

plications, 

omplications, 

mplications, and

ated Lower Extremity

BACKGROUND:More than 18 million Americans (6 percent of the population) havediabetes, though experts estimate that nearly 30 percent of thispopulation remains undiagnosed. The number of people diagnosedwith this condition is expected to increase 44 percent by 2020. Amongthose at highest risk are older Americans: the number of diagnosedpatients among this population is expected to increase 56 percentwithin this same time period.2 The increase in diabetes has been linked

to a number of other factors, including the rise in obesity in the UnitedStates observed within the last 2 decades.3, 4, 5

The costs of treating this chronic disease are tremendous. The AmericanDiabetes Association estimates that the total national cost of diabeteswas $132 billion in 2002; of this figure, nearly $92 billion was spent ondirect medical costs, and $40 billion went toward indirect costs relatedto disability, work loss, and premature mortality.6The Institute of Medicine has identified this disease as a priority areafor improvement of health care quality.7 Providing high quality care for

diabetes management and treatment engages the health care system atall levels. Providers need to ensure that patients are properly diagnosed,educated, and treated. Furthermore, individuals with diabetes need toproactively manage their disease and work toward preventing secondarycomplications.Timely diagnosis, effective ambulatory care, and appropriate diseasemanagement may reduce the need for hospital admissions for diabetes.Healthy People 2010, a report issued by the U.S. Department of Healthand Human Services, established a target hospitalization rate of 54 per100,000 population for persons 18–64 years of age with uncontrolleddiabetes.8 This goal applies to individuals treated for uncontrolled

diabetes with and without short-term complications.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

25

Chronic Conditions

■ Hospitalization rates for uncontrolled diabetes without

complications dropped by nearly 30 percent between 1994 and2000, while rates for short-term complications increased by9 percent.

■ The West has the lowest rates of hospitalization across all 4 diabetesrelated indicators. Geographic variation is greatest for treatment of

uncontrolled diabetes without complications; for this condition,admissions vary by more than 100 percent between the regions withthe highest and lowest rates.

■ Compared with adults 18–44 years of age, the elderly are more likely

to be hospitalized for the long-term complications of diabetes butless likely for short-term complications.
■ Women are 50 percent less likely than men to experience diabetesrelated lower extremity amputations during hospitalization.■ Dramatic differences exist across community income groups;

residents from the lowest income areas have the highest rates ofhospitalization for all diabetes-related conditions.

■ Although admission rates for most diabetes-related indicators do

not vary by patient residence, rural residents are more likely thanurban dwellers to be admitted to the hospital for uncontrolleddiabetes without complications.
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

27

Chronic Conditions

ORY DISEASES:

rt Failure,

and 

t a Procedure

rtension, and angina without a procedure

as identified by the Institute of Medicine

he U.S. population.9

tive heart failure (CHF) typically have 

The elderly are at especially high risk for

s the most frequent discharge diagnosis

s. In 1999, Medicare paid $3.6 billion for

rthermore, approximately 5 million

en diagnosed with CHF; the associated

illion.10

ed great concern within the U.S. This

han 50 million Americans, representing

ult population.11 According to the American

Heart Association, the lifetime risk of developing hypertension isapproximately 90 percent for adults between ages 55 and 65; one-thirdof those affected are not even aware they have this condition.12, 13

In 2004, the total cost of treating hypertensive patients was estimated tobe $55.5 billion, and 75 percent of these expenses were allocated fordirect medical costs.14While less widespread, angina without a procedure persists as asignificant health condition in the U.S. In 2001, approximately 7million people were diagnosed with angina.15 The American Heart

Association estimates that 27 percent of men and 14 percent ofwomen will develop this condition within 6 years of experiencing aheart attack.16 While not all angina admissions are preventable, it may

be possible to effectively manage this condition on an outpatient basisif diagnostic procedures and/or surgical interventions are not required.Although occasional hospitalization may be necessary, each ofthese conditions can usually be controlled in outpatient settings.Patient compliance with treatment and appropriate lifestylebehaviors may lower the likelihood of hospitalization, and admissionrates may be further reduced by ensuring access to high qualityoutpatient care.
■ Admission rates for angina without a procedure decreased markedly

between 1994 and 2000, dropping by 71 percent (to 66 admissionsper 100,000 population).iv

■ Regional variation is greatest among hypertension admissions;

hospitalization rates in the South are nearly twice as high as rates inthe West, the region characterized by the lowest admission rates.

■ The likelihood of hospitalization increases as community income

decreases; this inverse relationship is most apparent for treatment of CHF.

■ Rural residents are 87 percent more likely than urban residents to 

be admitted for treatment of angina without a procedure.

iv This decline in admissions may be related to several factors, including increased use of procedures; shifting

care from inpatient to outpatient settings; improved clinical training, technology, and patient ability torecognize symptoms; and more effective drugs.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

29

Chronic Conditions
TORY DISEASES:

a, 

hma, and 

ructive 

isease

ns diagnosed with asthma has more than

2000, more than 25 million Americans 

h this chronic condition.17, 18 Vulnerable

sk of acquiring asthma include children and

he American Lung Association reports that

s amount to more than $9 billion annually,

ng from lost productivity equal approximately

 vast resources spent on treating this disease,

nue to experience serious consequences.

 in nearly 2 million visits to the emergency

deaths.21 Death from asthma sparks particular

come is almost always avoidable with timely

While asthma prevalence has increased over time, hospitalizations forthis condition improved between 1994 and 2000. However, currentadmission rates still fall short of the objectives set forth by the U.S.Department of Health and Human Services. In its report, HealthyPeople 2010, the Department establishes target hospitalization rates of77 per 100,000 population for people ages 5–65 years, and 25 per100,000 population for children under the age of 5 years.22 Although

the PQIs focus on different age groups, the results presented in thefollowing pages illustrate that more work is needed to attain thesegoals. In 2000, admission rates were 201 per 100,000 children 0–17years of age, and 113 per 100,000 adults 18 years and older.Chronic obstructive pulmonary disease (COPD) also warrantsattention, particularly because of the large number of cases that are notdiagnosed. In 2001, when more than 12 million adults were diagnosedwith COPD, experts estimate that an additional 16 million remainedundiagnosed and, therefore, untreated.23, 24 Failure to treat patients with

COPD is a significant problem because this disease can be fatal. In fact,COPD is the fourth leading cause of death in the United States.25

Furthermore, COPD is a costly disease. In 2000, national COPD coststotaled more than $32 billion; this amount was split nearly evenlybetween direct and indirect costs.26For most populations, asthma and COPD can often be managed withproper outpatient therapy, patient compliance with treatment, andabstinence from smoking. These factors, combined with access to highquality primary and preventive care, can reduce the severity of theseconditions and the need for hospitalization.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Chronic Conditions

31

■ Admission rates for asthma improved over time: adults experienced

a steady decline in admissions between 1994 and 2000, and childrenwere much less likely to be hospitalized in 2000 than in 1997.

■ COPD admissions rose substantially during the 6-year study period;

hospitalization rates increased by 20 percent.

■ Variation in hospitalizations is most dramatic for treatment of

COPD; hospitalization rates in the West are nearly half the ratesobserved in the South, the region with the highest admission rates.

* = statistically different from (a) at p≤0.05. Rates are adjusted by age and sex, using year 2000 as the

standard population.

a Admission rate populations vary by type of condition. Adult asthma and chronic obstructive pulmonary

disease include individuals 18 years and older, and pediatric asthma includes children less than 18 years of age.
■ Likelihood of admission is related to patient age: children below

the age of 5 are 2 to 6 times more likely to be hospitalized forasthma than are older children, and adults 65 and above are morethan 4 times more likely to be admitted for COPD than adults45–64 years of age.

■ Adult asthma admission rates are 2.5 times higher for women than

for men, whereas pediatric asthma admission rates are nearly onethird lower for girls than for boys.

■ For each of the 3 respiratory diseases, hospital admission rates

decline as community income rises; rates are more than 2 timeshigher for residents of low-income areas than for residents of thehighest income areas.

* = statistically different from (a) at p≤0.05. Rates are adjusted by age and sex, using year 2000 as the

standard population.

a Admission rate populations vary by type of condition. Adult asthma and chronic obstructive pulmonary disease

include individuals 18 years and older, while pediatric asthma includes children less than 18 years of age.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Chronic Conditions

33
ONDITIONS:

umonia, 

 

 Infections, 

ppendix, and 

troenteritis

BACKGROUND:Several acute conditions pose significant challenges for the U.S. healthcare system. Many of these, such as bacterial pneumonia, dehydration,urinary tract infections, and perforated appendix, impact people ofall ages. Each of these conditions may pose greater risks for specificsubgroups, and others may target limited populations. For example,gastroenteritis is considered a potentially serious health problemamong children.The most common form of bacterial pneumonia is pneumococcalpneumonia, which accounts for 9 out of 10 disease cases. Thiscondition results in as many as 800,000 hospitalizations each year.27Older Americans are particularly susceptible, although researchindicates that vaccines can be 45 percent effective in preventing theneed for hospitalization among this population during peak seasons.28Furthermore, this condition can often be treated with antibiotics, andprompt, effective outpatient treatment can help prevent unnecessaryhospital admissions.Certain populations are especially vulnerable to dehydration, includingolder Americans and very young children. This condition can often betreated in outpatient settings and, in many cases, hospital treatmentmay be unnecessary. However, inadequate treatment can result inserious complications, including mortality.29Urinary tract infections (UTIs) are most common among women,although some men may also experience these types of infections.Estimates indicate that 50 to 80 percent of women develop at least 1UTI during their lifetime, compared with 12 percent of men.30, 31Approximately 20 to 50 percent of all women experience recurrentinfections and each year 11 percent of American women reportsuffering from UTIs.32, 33 These infections are treated most frequently

with antibiotics; the annual national cost of UTI prescriptions wasestimated at more than $1.5 billion in 1995.34
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Acute Conditions

35

when appropriate treatment for acute

s may arise from providers’ misdiagnosis,

 symptoms as important, or system factors

urgery (e.g., hospital surgical rooms are

the other hand, prompt diagnosis and

he progression of acute appendicitis to

e incidence of perforated appendix.

ns involving treatment for this condition

ore of the previously described areas.

e irritation and inflammation of a child’s

 result of a number of factors, including

n, and intestinal parasites. This condition

care settings with proper hydration and

ins one of the most common reasons for

en. Each year, pediatric gastroenteritis

0 percent of all hospitalizations for

.35

he likelihood of contracting these

al surroundings and proper hygiene can

ny of these illnesses. In addition, if patients

periencing symptoms, and if physicians

ent in outpatient settings, the need for

eased significantly. Therefore, rates of

sed to evaluate the quality of primary and

mission rates may reflect better overall

vided in outpatient settings.
■ Between 1994 and 2000, hospitalization rates for perforated

appendix decreased 9 percent, rates for dehydration and urinarytract infection did not change substantially, and rates for bacterialpneumonia increased by 9 percent.

■ The South has the highest admission rates and the West has the

lowest admission rates for 4 of 5 acute conditions.

■ Among hospitalizations involving treatment for perforated

appendix, the Northeast has the lowest rate, while the 3 other Census regions have comparable rates of roughly 320 admissions per 100,000 population.

■ The likelihood of hospital admission is inversely related to

community income: residents from the lowest income areas aremore likely than residents of higher income areas to be hospitalizedfor each of the acute conditions.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Acute Conditions

37

■ Young children age 0–4 years are 6 to 11 times more likely to be

hospitalized for pediatric gastroenteritis than older children.

■ Among adults, preventable hospitalization rates for acute conditions

increase substantially with age. The elderly are 5 to 6 times morelikely to be admitted for bacterial pneumonia, dehydration, andurinary tract infections than adults 45–64 years of age.

■ Compared with men, women have higher admission rates for

dehydration and urinary tract infections but lower rates forbacterial pneumonia and perforated appendix.

* = statistically different from (a) at p≤0.05. Rates are adjusted by age and sex, using year 2000 as the

standard population.

a Admission rate populations vary by type of condition. Bacterial pneumonia, dehydration, urinary tract

infections, and perforated appendix include individuals of all ages; pediatric gastroenteritis includes children

less than 18 years of age.
higher among rural residents for 4 of 5 acute

 pneumonia, dehydration, urinary tract

ric gastroenteritis.

≤0.05. Rates are adjusted by age and sex, using year 2000 as the

ype of condition. Bacterial pneumonia, dehydration, urinary tract

clude individuals of all ages; pediatric gastroenteritis includes children
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

39

Birth Outcomes

TCOMES:

ths

BACKGROUND:The proportion of newborns weighing less than 2,500 grams hasincreased steadily since the mid-1980s. By 2002, the rate of low-weightbirths reached the highest level observed over the past 3 decades. Thistrend may be partially explained by the increased use of assistedreproductive technologies, which often results in multiple births.36At the same time, other factors influence the likelihood of low-weightbirth, such as prenatal care. Because prenatal care is delivered inprimary care settings, data on these services are not widely available.As a result, it is difficult to define and evaluate the effectiveness ofadequate prenatal care. However, some studies have found that motherswho obtain prenatal care have fewer low-weight newborns than womenwho do not receive such preventive care.37 Research also suggests 

that the following factors may be particularly effective in preventinglow-weight births: smoking cessation, proper maternal nutrition, andadequate treatment of maternal comorbidities.38

The Institute of Medicine classified pregnancy and childbirth as apriority area, and the U.S. Department of Health and Human Services’report, Healthy People 2010, established a goal of reducing theproportion of low birthweight infants to 50 per 1,000 of allnewborns.39, 40
■ The South has the greatest number of low-weight births per 100,000

neonates, while the West has the fewest; the West’s low-weight birthrate is 15 percent below the average of the 3 other regions.

■ Low-weight birth rates decline with increasing community income;

rates vary by one-third between residents of the highest and lowestincome areas.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

41

Birth Outcomes

■ Rates of low-weight births are comparable between newborns with

private insurance and those who are uninsured.v

■ Medicaid enrollees have higher low-weight birth rates than any other

payer group; rates are 38 percent higher for newborns covered byMedicaid than for newborns with private insurance.

v When calculating admission rates, the Low-Weight Birth PQI uses the number of neonates in the denominator.

Because HCUP databases provide the number of births, it is possible to calculate rates for each payer groupand make comparisons. All other PQIs use population-based denominators, which are available through theU.S. Census, Current Population Survey, and Claritas Census projections. These data sources define payer groupsdifferently than the HCUP databases; therefore, it is not possible to calculate admission rates by payercategories for all other PQIs.
o

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evention

Indicators 

y Indicators (PQIs) are a set of measures 

hospital inpatient discharge data to identify

ve conditions.” These are conditions for 

are can potentially prevent the need for

hich early intervention can prevent

evere disease.41, 42

tors are based on hospital inpatient data,

 the quality of the health care system outside

example, individuals with diabetes may be

complications if their conditions are not

 if they do not receive the patient education

elf-management.

6 ambulatory care sensitive conditions listed

n the Prevention Quality Indicators,

ation and software available at

ators.ahrq.gov/data/hcup/prevqi.htm.

the AHRQ Quality Indicators,

y Indicator Support Team at

rs.ahrq.gov.

CHRONIC CONDITIONSDiabetes■ Uncontrolled diabetes without complications■ Short-term diabetes complications■ Long-term diabetes complications■ Lower-extremity amputation among patients with diabetes

Circulatory Diseases

■ Congestive heart failure■ Hypertension■ Angina without a procedure

Respiratory Diseases

■ Adult asthma■ Pediatric asthma■ Chronic obstructive pulmonary diseaseACUTE CONDITIONS■ Bacterial pneumonia■ Dehydration■ Urinary tract infection■ Perforated appendix■ Pediatric gastroenteritisBIRTH OUTCOMES■ Low-weight birth
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Source of Data

45

Data for 

rt

 report are drawn from the Healthcare 

ct (HCUP), a Federal-State-Industry

State health care data system. This

he Agency for Healthcare Research and

aged by staff in AHRQ’s Center for

Markets. HCUP is based on data collected

ganizations (including State departments

ns, and private agencies), which then

CUP would not be possible without

ects and their partnership with AHRQ.

rtner organizations contributed data to

alidated and converted into a uniform

databases enable comparative studies of

se and cost of hospital care, including:

ces on hospitals and the care they provide

ctice

cal technology and treatments 

 populations.

non-Federal, community hospitals as

pital Association. This definition includes

y facilities, such as pediatric, obstetrics

spitals. The HCUP State Inpatient

 short-term rehabilitation facilities.

ic hospitals are excluded, as are substance

HCUP includes several sets of inpatient databases for health servicesresearch. This report is based on Nationwide Inpatient Sample (NIS)data for years 1994, 1997, and 2000.vi The NIS is the largest all-payer

inpatient care database that is publicly available in the United States.The database contains data for 5 to 8 million hospital stays fromroughly 1,000 hospitals sampled to approximate a 20 percent stratifiedsample of U.S. community hospitals.vii The data are weighted to obtain

estimates representing the total number of inpatient hospital dischargesin the U.S.; in the year 2000, this figure was approximately 36.4 million.

viBy 1994, 17 State Partners participated in HCUP (AZ, CA, CO, CT, FL, IL, IA, KS, MD, MA, NJ, NY, OR, PA, SC,

WA and WI). By 1997, 5 additional State Partners (GA, HI, MO, TN and UT) participated. By 2000, 7 additionalstates (KT, ME, MI, NC, TX, VA, and WV) participated in HCUP. While Michigan participated in HCUP during2000, Michigan data were not included in the 2000 NIS. Thus, analyses conducted for the Fact Book are basedon 2000 NIS data sampled from 28 State Partner databases.

viiStarting in the year 2000, short-term rehabilitation hospitals are not included in the HCUP Nationwide

Inpatient Sample (NIS).
HRQ Prevention Quality Indicators are 

Nationwide Inpatient Sample hospital

Quality Indicators identify hospital admissions

oided, at least in part, through high quality

QIs are based on existing measures that have

researchers and used in analytic studies.43

ely on hospital inpatient administrative data

e as screens to examine quality and identify the

tudies. The PQIs were originally developed by

ently revised and improved under contract

ersity of California, San Francisco–Stanford

rd) Evidence-Based Practice Center.

o apply the AHRQ Prevention Quality

pital discharge data for this study:

ewed and modified to allow for the generation 

 using a weighted NIS.

-based data were acquired for the reporting 

dy.

pared for consistency over time and data sets 

udinal changes in ICD-9 codes.

were developed for hypothesis testing.

lying AHRQ Quality Indicators to Healthcare

ect (HCUP) Data for the National Healthcare

e from AHRQ upon request, describes these

The Prevention Quality Indicators develop admission rates usingHCUP inpatient hospitalization data and population data from the2000 Census and Claritas.45 Admission rates are based on principal

diagnosis for all measures except diabetes-related lower extremityamputations, perforated appendix, and low-weight births. For thesethree PQIs, counts are included in the numerators if the condition ofinterest is indicated in any diagnosis field. The PQIs for perforatedappendix and low-weight births use hospital discharges in thedenominators, rather than general population groups. Diagnoses areidentified using codes of the International Classification of Diseases, 9th

Revision, Clinical Modification (ICD-9-CM). Risk adjustments aremade for age and gender differences based on methods of directstandardization.46
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

47

References

s

produced by AHRQ staff using the 2000

 Sample. Costs are based on charges

reported by hospitals to the Center for

ces.

and Prevention. 2002. National Diabetes

ov/diabetes/pubs/factsheet.htm. Accessed

n B, Dietz W. 2003. Prevalence of obesity,

health risk factors, 2001. Journal of the

, 289(1):76–79.

m Research Group. 2002. Reduction in the

with lifestyle intervention or metformin.

cine, 346(6):393–403.

and Prevention. U.S. Obesity Trends 1985 to

dphp/dnpa/obesity/trend/maps/index.htm.

on. Costs of Diabetes in U.S., 2002.

.

Priority Areas for National Action:

uality. Washington, DC: National

and Human Services. November 2000.

anding and Improving Health. 2nd ed.

nment Printing Office.

Priority Areas for National Action:

ality. Washington, DC: National

10American Heart Association. 2003. Heart Disease and Stroke Statistics

— 2004 Update. Dallas, TX: American Heart Association.

11National Institutes of Health. High Blood Pressure.

http://123819272.net/Diseases/Hbp/HBP_WholsAtRisk.html.Accessed January 14, 2004.

12American Heart Association. 2002. Heart Disease and Stroke Statistics

— 2003 Update. Dallas, TX: American Heart Association.

13American Heart Association, 2003.14 Ibid.15 Ibid.16American Heart Association, 2002.17U.S. Department of Health and Human Services. 2000. Action 

Against Asthma: A Strategic Plan for the Department of Health andHuman Services. http://aspe.hhs.gov/sp/asthma. Accessed December

15, 2003.

18Krauss, N. March 2003. Statistical Brief #13: Asthma Treatment: 

Use of Medications and Devices, 2000. Rockville, MD: Agency forHealthcare Research and Quality.http://www.meps.ahrq.gov/PrintProducts/PrintProd_Detail.asp?ID=489.Accessed December 15, 2003.

19 Ibid.20American Lung Association. March 2003. Trends in Asthma Morbidity

and Mortality. http://www.lungusa.org/data/asthma/asthma1.pdf.Accessed December 15, 2003.

21U.S. Department of Health and Human Services, 2000.
alth and Human Services. November 2000.

derstanding and Improving Health. 2nd ed.

vernment Printing Office.

Health. 2003. Data Fact Sheet: Chronic

isease. NIH Publication No. 03-5229. Bethesda,

of Health.

tion. 2001. Breathless in America: COPD at a

usa.org/press/lung_dis/asn_copdglance.html.

003.

ealth, 2003.

eumococcal vaccination in the prevention 

pneumonia: An optimistic view of cost

 Respiratory Infection, 8(4):285–293.

urumoto-Dawson A, et al. 1992. Influenza

reventing hospitalization for pneumonia in the

of Epidemiology, 136(3):296–307.

 KL. 1995. Dehydration: Evaluation and

ults. Journal of the American Medical

–1556.

9. Infections in the urinary tract. Scientific

me 2, Part 7:1–9. New York, NY: Scientific

sociation. Urinary Tract Infections in Adults.

h.org/print/index.cfm?topic=147. Accessed

32 Gupta K, Rubin R. 1999. Infections in the urinary tract. Scientific

American Medicine, Volume 2, Part 7: 1–9. New York, NY: ScientificAmerican.

33 Foxman B, Barlow R, D’Arcy H, et al. 2000. Urinary tract infection:

Self-reported incidence and associated costs. Annals of Epidemiology,10(8):509–515.

34 Ibid.35 Murkhart DM. 1999. Management of acute gastroenteritis in children.

American Family Physician, 60(9):2555–2566.

36 Martin JA, Hamilton BE, Sutton PD, et al. 2003. Births: Final Data for

2002. National Vital Statistics Reports, 52(10):17–18.

37 Shiono PH, Behrman RE. 1995. Low Birth Weight: Analysis and

Recommendations. The Future of Children, 5(1):4–18.

38Alexander GR, Korenbrot CC. 1995. The Role of Prenatal Care in

Preventing Low Birth Weight. The Future of Children, 5(1):103–120.

39 Institute of Medicine. 2003. Priority Areas for National Action:

Transforming Health Care Quality. Washington, DC: National Academies Press.

40U.S. Department of Health and Human Services. November 2000.

Healthy People 2010: Understanding and Improving Health. 2nd ed.Washington, DC: U.S. Government Printing Office.

41Agency for Healthcare Research and Quality. 2001. AHRQ Quality

Indicators — Guide to Prevention Quality Indicators: Hospital Admissionfor Ambulatory Care Sensitive Conditions, AHRQ Pub. No. 02-R0203.Rockville, MD: Agency for Healthcare Research and Quality.
HCUP Fact Book No. 5 ■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

References

49

lellan M, et al. May 2001. Refinement of

. Technical Review Number 4 (prepared

Based Practice Center under Contract No.

o. 01-0035. Rockville, MD: Agency for

ality.

arch and Quality. 2001. AHRQ Quality

ntion Quality Indicators: Hospital

are Sensitive Conditions. Rockville, MD:

ch and Quality. AHRQ Pub. No. 0-R0203.

ens B, et al. June 2003. Methods Applying

Healthcare Cost and Utilization Project

al Healthcare Quality Report. Deliverable

der Contract No. 290-00-004).

 Claritas Demographic Update Methodology.

ethods for Rates and Proportions. New York,
dure) — Angina is a severe, often constricting

ss, or pressure experienced primarily in the

lt in the left shoulder, arms, neck, back, and

 early sign of coronary artery disease. While

 are preventable, it is possible that angina can

n an outpatient basis if diagnostic procedures

ons are not required.

 lung disease is characterized by an

s and may involve muscle spasms and airway

ymptoms of asthma include: coughing,

reath, and chest tightness. Asthma may be

ironmental factors, including pollen, dust,

eather, and strong emotions.

Infection of the lungs caused by bacteria that

g, and congestion of the lungs.

monary disease (COPD) — Common name

ting conditions of chronic bronchitis and

onchitis is an inflammation of the lungs 

the lungs and constriction of the airways.

flammation of the lungs leading to swelling

ally breaks the walls in between the air sacs.

e the elasticity of the lungs and impair the

carbon dioxide.

(CHF) — A weakness in the heart muscle,

attack, heart disease, high blood pressure, or

 ability of the heart to effectively pump blood

y to effectively pump and circulate blood

ds to pooling of blood in the extremities and

Dehydration — Excessive loss of water and salt that can lead to

dangerous side effects. Dehydration is usually classified as mild,moderate, and severe with symptoms. Mild and moderate dehydrationare characterized by symptoms ranging from dry mouth and rapidheart beat to sunken eyes and lethargy. Severe dehydration can lead toshock, seizure, brain damage, and death.Diabetes — The body’s inability to produce insulin (type 1 diabetes) or properly use insulin (type 2 diabetes) that has been produced.Complications from diabetes can be categorized as follows:

Short-term complications — Conditions include diabeticketoacidosis, hyperosmolarity, and coma. These life-threateningconditions occur when a patient experiences excess glucose orinsulin.Long-term complications — Conditions include renal, visual,

neurological, and circulatory disorders.Lower extremity amputation — Long-term circulatory problemscaused by diabetes can lead to gangrene and necrosis of themuscle and skin in the legs; often, these complications will lead to the amputation of the feet and/or legs. Lower extremityamputations are often preventable with proper diseasemanagement. Hospitalizations involving these procedures signalsignificant problems in the quality of primary and preventive carethat might have been provided earlier in the disease progression.

Hypertension — Also known as high blood pressure, hypertension is the elevation of blood pressure to a level sufficient to causecardiovascular damage. The official criterion for hypertension is asystolic reading of 140 or higher and a diastolic reading of 90 or higher.Low-weight birth — Birth weight less than 2,500 grams.
HCUP Fact Book No. 5 

■ Preventable Hospitalizations: A Window Into Primary and Preventive Care, 2000

Glossary

51

Pediatric gastroenteritis — Irritation and inflammation of the

digestive tract in children. Common symptoms include abdominal

pain, diarrhea, vomiting, nausea, and dehydration. A variety of

environmental factors may be responsible, including food poisoning,

viral infection, and intestinal parasites.

Perforated appendix — A tear in the appendix usually caused by

swelling from appendicitis. This perforation allows the contents of the

appendix to be released into the abdominal cavity and can lead to a

serious infection (peritonitis).

Region — For this report, States are included in the four U.S. Census

regions as follows:

■ Northeast — Connecticut, Massachusetts, Maine, New

Hampshire, New Jersey, New York, Pennsylvania, Rhode

Island, Vermont

■ Midwest — Illinois, Indiana, Iowa, Kansas, Michigan,

Minnesota, Missouri, Nebraska, North Dakota, Ohio, South

Dakota, Wisconsin

■ West — Alaska, Arizona, California, Colorado, Hawaii,

Idaho, Montana, Nevada, New Mexico, Oregon, Utah,

Washington, Wyoming

■ South — Alabama, Arkansas, Delaware, Florida, Georgia,

Kentucky, Louisiana, Maryland, Mississippi, North Carolina,

Oklahoma, South Carolina, Tennessee, Texas, Virginia, West

Virginia.

Urban/rural residence — This report defines patient residence as urban

or rural based on the 1990 definition of the U.S. Office of Management

and Budget. Thus, location of patient’s residence is defined as:

■ Urban — Patient’s ZIP Code is located in a metropolitan

statistical area (MSA)

■ Rural — Patient’s ZIP Code is located outside a MSA.

Urinary tract infection — Infection that occurs when bacteria enters

the urethra. The infection may spread from the urethra to the rest of

the urinary tract, including the bladder, ureters, and kidneys.

Note: Definitions are derived from 3 sources: (1) AHRQ Quality Indicators — Guide to Prevention Quality

Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Rockville, MD: Agency for Healthcare

Research and Quality, 2001. AHRQ Pub. No. 0-R0203; (2) Stedman’s Medical Dictionary — 27th Edition. 2000.

Baltimore, MD: Lippincott Williams & Wilkins; (3) Agency for Healthcare Research and Quality. 2002. Description

of Data Elements: Nationwide Inpatient Sample (NIS), Hospital Weights File, 2001. http://www.hcup-us.

ahrq.gov/db/nation/nis/dbdoc/DataElements_NIS_2001_HOSPITAL.pdf. Accessed January 23, 2004. 
 Information

arding HCUP data is available at 

v/data/hcup, as well as on the HCUP User

p://www.hcup-us.ahrq.gov. Detailed

HRQ Quality Indicators is available at

tors.ahrq.gov.

atistics can be viewed through HCUPnet

ata/hcup/hcupnet.htm), a Web-based tool

nformation on hospital stays.

ABLE INCLUDE:

)710)

o 2001 can be purchased for research through

ibutor sponsored by AHRQ: Social and

lephone: (866) 556-4287 (toll-free), fax: (301)

p@s-3.com.

Price of the data is $322 for Release 1; $160 per year for 1993 to 1999;and $200 per year for 2000 and 2001. All prices may be higher forcustomers outside the United States, Canada, and Mexico.AHRQ is always looking for ways in which AHRQ-funded research,products, and tools have changed peoples' lives, influenced clinicalpractice, improved policies, and affected patient outcomes. Impactcase studies describe AHRQ research findings in action. These casestudies have been used in testimony, budget documents, andspeeches. If you are aware of any impact AHRQ-funded research orproducts, such as HCUP, have had on health care policy, clinicalpractice, or patient outcomes, please let us know using the contactinformation below.Healthcare Cost and Utilization Project (HCUP)Center for Delivery, Organization, and MarketsAgency for Healthcare Research and QualityPhone: (866) 290-HCUP E-mail: HCUP@AHRQ.gov

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U.S. Department of Health and Human ServicesAgency for Healthcare Research and Quality540 Gaither RoadRockville, MD 20850www.ahrq.gov