Avoidable Hospital Admissions from Diabetes-related Complications: Evidence from Japan, Singapore and Hong Kong, and Communities Outside Beijing

Abstract

Research Objective: 1) To analyze avoidable admissions for diabetes-related complications and related spending patterns in Japan, Singapore, and Hong Kong, and Beijing, China, in the period 2008–14. 2) To conduct empirical analysis of whether outpatient visits and inpatient admissions were positively or negatively correlated in our study samples, and whether that pattern differed across study sites. Study Design: We identified avoidable admission among people diagnosed with diabetes in four study sites in East Asia, and compared the rates to those in other middle- and high-income countries (adjusting for age and sex). Avoidable hospital admissions were identified using the criteria set by the 2014–15 OECD Health Care Quality Indicators. This source represents an international quality metric to capture variations in health service utilization patterns across countries. To examine whether the number of outpatient visits in 2012 was positively or negatively correlated with the probability of an avoidable admission in 2013 at the individual patient level, we used a probit regression model that controlled for age, age squared, sex, smoking status, HbA1c (a marker of diabetes control), and Elixhauser comorbidities. We also included the Charlson Comorbidity Index (a marker of severity) in the regression model, as a sensitivity analysis. Population Studied: People with diabetes in Japan, Singapore, Hong Kong, and rural and peri-urban Beijing, China, in the period 2008–14. Cases were defined as non- maternal hospital admissions that had a principal ICD-9 or ICD-10 diagnosis code for a diabetes-related complication. We analyzed data from the Japan Medical Data Center, Singapore Ministry of Health, Hong Kong Hospital Authority, and Beijing New Cooperative Medical (insurance) Scheme. Principal Findings: We found significant variations in diabetes-related avoidable hospital admission rates across four study sites in East Asia. Spending on these admissions increased from 2006 to 2014 and is substantial: Annual medical expenditures for people with an avoidable admission were six to twenty times those for people without such an admission. In all of our study sites, when we controlled for severity, we found that people with more outpatient visits in a given year were less likely to experience an avoidable admission in the following year. Conclusions: We found empirical evidence that a higher number of outpatient visits in a given year was negatively correlated with the probability of an avoidable admission in the following year, which implies that primary care management of diabetes has the potential to improve quality and achieve cost savings. Implications for Policy or Practice: In East Asia, as in other parts of the world, policy interventions that increase access and adherence to effective outpatient management potentially improve health outcomes while realizing cost savings from reduced avoidable hospital admissions. Interventions that improve access (such as providing more out-of-hours care), greater continuity of care with a general practitioner, and improving the quality and status of primary care may be associated with lower rates of avoidable hospital admission. Policy interventions may improve the net value of care if savings in inpatient spending more than offset the increase in outpatient spending.