Racial differences in age at hospitalization for ambulatory care sensitive conditions demonstrate that blacks are hospitalized for these conditions prematurely, even after controlling for individual and hospital characteristics likely to influence hospitalizations. Blacks were hospitalized at significantly younger ages than whites for all causes, chronic conditions, acute conditions, and the following conditions: uncontrolled diabetes, bacterial pneumonia, diseases of the circulatory system (congestive heart failure, hypertension), COPD, and dehydration. No racial disparities were detected for asthma, short-term complications of diabetes, or urinary tract infections. Differences in age at hospitalization for long-term diabetes complications were attenuated by sociodemographic characteristics.
Beyond identifying disparity in rates of disease or risks of hospitalization, identifying disparity in age at hospitalization provides deeper insight into the social and economic consequences of disparities on individuals, families and communities. Premature hospitalizations due to preventable ambulatory care-sensitive conditions result in substantial economic burden to society, with treatment estimated to exceed $263 billion annually.31
Moreover, these costs are dwarfed by secondary costs and long-term sequelae. Families must endure direct costs through rising out-of-pocket expenses and lost days of work.32,33
Poor health, particularly resulting from more severe diseases or disease complications, can lower social status, by limiting a person’s ability to work, wages earned, and level of education attained, resulting in lower SES for the family within one to two generations.34–37
For example, consider direct and indirect health and economic consequences of hospitalization for uncontrolled diabetes for a black man aged 46 years compared to a white man aged 58 years.
Reducing disparities and promoting equity in health will require challenging systems-level changes. A recent Kaiser Family Foundation brief outlined priorities to reduce disparities: (1) increase public/provider awareness of disparities, (2) expand health insurance coverage, (3) improve capacity in underserved areas, and (4) increase the knowledge base of intervention strategies.38
With the current economic downturn, escalating healthcare costs, and persistent systemic disparities, a window of opportunity to make these changes exists.39
Because blacks are disproportionately uninsured and thus have less access to routine care, expanding and enhancing programs such as Medicaid and SCHIP could promote health equity.40
Finally, a commitment to prevention could reduce unnecessary hospitalizations across all racial/ethnic groups.
This study has several limitations. The data did not allow a determination of whether these were first or repeat admissions for ambulatory care-sensitive conditions. Using discharge records with incomplete data on SES and comorbid conditions limits the extent to which underlying causes can be disentangled. Primary sampling units are not available in the public use files of the NHDS; therefore, generalized linear models could not be performed and robust SEs had to be calculated to account for the dependence of individuals within clusters.27,28
Finally, because data were collected using discharge records, missing data and measurement error may be problematic. One quarter of discharges were missing information on race. A previous review of this data source indicated that the majority of Hispanics did not report a specific race, and therefore would be appropriately excluded. 26,27,41
Of Hispanics who reported race, 90% reported race as white. Because Hispanics in the U.S. are younger on average than whites,42
this would likely lead to an underestimation of the noted difference. This study also has several notable strengths, utilizing data from a representative, national sample of more than 6,800 hospital discharges. The focus on ambulatory care-sensitive conditions, which are frequently used measures, can be easily replicated. Moreover, this can serve as a common metric through which changes over time can be documented. This is the first study to examine racial disparities in age at hospitalization for each ambulatory care-sensitive condition separately, thus providing more detailed documentation of observed disparities. Results of this study highlight the impact that younger age at hospitalization may have on the social and economic well being of individuals and their families, through loss of wages, poorer quality of life, and risk for a greater number of hospitalizations and severity of illness over the life span. Therefore, this focus on ambulatory care-sensitive conditions has important implications for future prevention efforts designed to reduce health disparities and promote health equity.