Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland

Objective. —To determine whether uninsured and Medicaid patients have higher rates of avoidable hospitalizations than do insured patients. Design. —We used 1987 computerized hospital discharge data to select a cross-sectional sample of hospitalized patients. Population estimates from theCurrent Population Surveywere used to estimate rates of admission, standardized for age and sex. Setting. —Nonfederal acute care hospitals in Massachusetts and Maryland. Patients.—All patients under 65 years of age who were uninsured, privately insured, or insured by Medicaid. Hospitalizations for obstetric and psychiatric conditions were excluded. Main Outcome Measures. —Relative risk of admission for 12 avoidable hospital conditions (AHCs) identified by a physician panel. Results. —Uninsured and Medicaid patients were more likely than insured patients to be hospitalized for AHCs. Rates for uninsured patients were significantly greater than for privately insured patients in Massachusetts for 10 of 12 individual AHCs, and in Maryland for five of 12 AHCs. After adjustment for baseline utilization, the results were statistically significant for 10 of 12 AHCs in Massachusetts and seven of 12 AHCs in Maryland. For Medicaid patients, rates were significantly greater than for privately insured patients for all AHCs in each state before adjustment, and for nine of 12 and seven of 12 AHCs in each state, respectively, after adjustment for baseline utilization. Conclusion. —Our findings suggest that patients who are uninsured or who have Medicaid coverage have higher rates of hospitalization for conditions that can often be treated out of hospital or avoided altogether. Our approach is potentially useful for routine monitoring of access and quality of care for selected groups of patients. (JAMA. 1992;268:2388-2394)