Geographic variations in avoidable hospitalizations in the elderly, in a health system with universal coverage

Background: The study of Hospitalizations for ambulatory care sensitive conditions (ACSH) has been proposed as an indirect measure of access to and receipt of care by older persons at the entryway to the Spanish public health system. The aim of this work is to identify the rates of ACSH in persons 65 years or older living in different small-areas of the Community of Madrid (CM) and to detect possible differences in ACSH. Methods: Cross-sectional, ecologic study, which covered all 34 health districts of the CM. The study population consisted of all individuals aged 65 years or older residing in the CM between 2001 and 2003, inclusive. Using hospital discharge data, avoidable ACSH were selected from the list of conditions validated for Spain. Age- and sex-adjusted ACSH rates were calculated for the population of each health district and the statistics describing the data variability. Point graphs and maps were designed to represent the ACSH rates in the different health districts. Results: Of all the hospitalizations, 16.5% (64,409) were ACSH. Globally, the rate was higher among men: 33.15 per 1,000 populations vs. 22.10 in women and these differences were statistically significant (p < 0.05) in each district. For men the range was 70.82 and the coefficient of variation (CV) was 0.47, while for women the range was 43.69 and the CV was 0.48. In 93.1% of cases, the ACSH were caused by hypertensive cardiovascular disease, heart failure or pneumonia. A centripetal pattern can be observed, with lower rates in the districts in the center of the CM. This geographic distribution is maintained after grouping by sex. Conclusion: A significant variation is demonstrated in "preventable" hospitalizations between the different districts. In all the districts the men present rates significantly higher than women. Important variations in the access are observed the Primary Attention in spite of existing a universal sanitary cover.