Ambulatory Care Sensitive Conditions

1. Development of Ambulatory Care Sensitive
Conditions (ACSC) in Thai Context:
Hospitalization Rates for ACSC as Indicator
of Access and Quality in Primary Care
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
Arnat Wannasri. (Master student: NU; HISRO);
Nipaporn, S., Inmai, P., Sakunphanit, P., Srithamrongsawat, S., (HISRO);
Suriyawongpaisal, P. (Faculty of Medicine Ramathibodi Hospital, Mahidol University)

2. Introduction
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
• ACSCs are those conditions for which hospitalization
could be prevented by interventions in primary care.
• In many countries, hospitalization rates for ACSC are
used as a proxy for analyzing the quality of and access to
primary care services.
• Poor access and low quality of primary care  higher
hospitalization rates with ACSC.

3. Introduction
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
• Healthcare infrastructures in Thailand have been
developed for many decades to improve access to health
care and equity of service utilization across the country.
• Three levels of health care service system: Primary,
Secondary and Tertiary.
• Outpatient utilization rate: 2.45 visits/person in 2003 
3.22 visits/person in 2010.
• Better accessibility and what about the quality? 
population-based surveys!
• ACSC rate as indicator: helps states assess the quality of
and access to primary health care services, but “what is
ACSC list of Thailand?”

4. Aim of study
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สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
• Thailand has not yet been established this tool.
• “The aim of this study is to develop an ACSC list in
Thai context based on consensus among Thai
health professionals”.

5. Methodology
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
• Qualitative study: Delphi technique
• Working process as following:
1) The ACSC criteria: applied Caminal et al (2004)
- hospitalization rates of at least 1/10,000 populations;
- clarity in definition and ICD coding and;
- potentially preventable or avoidable through primary
care services.

6. Methodology
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
2) The health professional’s criteria:
- have experiences with primary care system more than
10 years
3) Questionnaire development
- Review of international and national literature
- Identified ICD-9, ICD-10 and procedure codes
- Analysing of hospitalization rates of each ICD code:
using public health insurance database of 3 health
schemes
- Making a questionnaire

7. Methodology
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข
4) Selection ACSC list: Consensus panel process
- 15 professionals give opinions: relationship between
ICD-code and primary care in the Thai context.
- 2 rounds for consensus (during July and August, 2013)
- Kappa test: analysing consensus level (≥ 0.41)
Kappa Interpretation
< 0 Poor agreement
0.0 – 0.20 Slight agreement
0.21 – 0.40 Fair agreement
0.41 – 0.60 Moderate agreement
0.61 – 0.80 Substantial agreement
0.81 – 1.00 Almost perfect agreement

8. Result: Literature review
THA U.S.A. BRA AUS CAN ESP UK TPE ITL
1 Acute Poliomyelitis √
2 Angina √ √ √ √ √ √ √ √
4 Asthma √ √ √ √ √ √ √ √ √
6 Bacterial pneumonia √ √ √ √
7 Cardiac insufficiency √
14 COPD √ √ √ √ √ √ √ √
31 Heart failure √
32 Hypertension √ √ √ √ √ √ √ √
34 Hypoglycemia √
35 Hypokamlemia √
36 Immunization and preventable √ √ √ √
37 Infectious diseases √
39 Influenza and pneumonia √ √ √
44 Nutritional deficiencies √ √ √ √
47 Pelvic inflammatory disease √ √ √ √ √ √ √
54 Seizure Disorder √
60 Urinary tract infections √ √
No. Disease groups
Countries

9. Result: Literature reviewNo. Disease groups ICD-10 ICD-9
1 Acute Poliomyelitis 045.00, 045.10, 045.20, 045.90
2 Angina
I20, I23.82, I24 (Exclude cases with
procedure codes 01 - 86.99)
411, 411.1, 411.8, 413
4 Asthma J45, J46 493
14 COPD
J10.0, J11.0, J12-J16, J18, J20-J21,
J22, J41-J44, J47, (J20: with
secondary diagnosis of J41-J44, J47),
(J10.0, J11.0, J12-J16, J18, J22: with
secondary diagnosis of J44)
491, 492, 494, 496, (466.0 with
secondary diagnosis of 491, 492,
494, 496)
16
Dehydration and
gastroenteritis
E86, K52.2, K52.8, K52.9,
18 Dental conditions
A69.0, K02-K06, K08, K09.8,
K09.9, K12, K13
521, 522, 523, 525, 528
20 Diabetes mellitus E10-E14 250.1, 250.2, 250.3, 250.7, 785.40
26
Ear, Nose and
Throat infections
H66, H67, J00-J03, J06, J31, I00-I02
33 Hypertension
I10, I11 (Excluding cases with caridac
procedures 33.6,35, 36, 37.3, 37.5,
37.7, 37.8, 37.94, 37.98)
401.0, 401.9, 402.0, 402.1, 402.9,
403.0, 404.0, 405.0, 437.2
37
Immunization and
preventable infectius
diseases
A15-A18, A33-A37, A50,-A53,
A80, A95, B05, B06, B16, B18.0,
B18.1, B26, B50-B54, B77, G00.0,
I00-I02, M01.4
033, 037, 072, 045, 055, 320.0,
390, 391., 037, 045, 320.0
60 Urinary tract N10, N11, N12, N13.6, N39.0 590.0, 590.1, 590.8, 590.9

10. Result: ICD-9 converts into ICD-10
Diseases ICD-9 codes Diseases ICD -10
045.00
Acute paralytic poliomyelitis specified as
bulbar, poliovirus, unspecified type A80.0,A80.1,A80.2
045.10
Acute poliomyelitis with other paralysis,
poliovirus, unspecified type A80.3
045.20
Acute nonparalytic poliomyelitis,
poliovirus, unspecified type A80.4
045.90
Acute poliomyelitis, unspecified,
poliovirus, unspecified type A80.9
411
Other acute and subacute forms of
ischemic heart disease I24.8,I24.9
411.1 Intermediate coronary syndrome I20.0
411.8
Other acute and subacute forms of
ischemic heart disease I24.8
413 Angina pectoris I20.0,I20.1,I20.8,I20.9
Acute Poliomyelitis
Angina

11. Next step
• Consensus panel round 1
 Kappa test analysis
 ICD codes with lower consensus level (≤ 0.41) will be
excluded.
 All relevant data will be used for the second round
• Consensus panel round 2
 Kappa test analysis
 ICD codes with accepted consensus level will be used as
ACSC list in the Thai context.
HealthInsuranceSystemResearchOffice
สำนักงำนวิจัยเพื่อกำรพัฒนำหลักประกันสุขภำพไทย เครือสถำบันวิจัยระบบสำธำรณสุข