Open Access Highly Accessed Research article

Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy

Nera Agabiti1*, Monica Pirani2, Patrizia Schifano1, Giulia Cesaroni1, Marina Davoli1, Luigi Bisanti3, Nicola Caranci4, Giuseppe Costa5, Francesco Forastiere1, Chiara Marinacci6, Antonio Russo3, Teresa Spadea5, Carlo A Perucci1 and Italian Study Group on Inequalities in Health Care

Author Affiliations

1 Epidemiology Department, Local Health Authority RM/E, Rome, Italy

2 Modena Cancer Registry, Modena, Italy

3 Epidemiology Department, Local Health Authority; Milan, Italy

4 Regional Agency for Health and Social Care - Emilia Romagna Region, Bologna, Italy

5 Epidemiology Department, Piedmont Region, Turin, Italy

6 Epidemiology Department, Local Health Authority, La Spezia, Italy

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BMC Public Health 2009, 9:457  doi:10.1186/1471-2458-9-457

Published: 11 December 2009



A relationship between quality of primary health care and preventable hospitalizations has been described in the US, especially among the elderly. In Europe, there has been a recent increase in the evaluation of Ambulatory Care Sensitive Conditions (ACSC) as an indicator of health care quality, but evidence is still limited. The aim of this study was to determine whether income level is associated with higher hospitalization rates for ACSC in adults in a country with universal health care coverage.


From the hospital registries in four Italian cities (Turin, Milan, Bologna, Rome), we identified 9384 hospital admissions for six chronic conditions (diabetes, hypertension, congestive heart failure, angina pectoris, chronic obstructive pulmonary disease, and asthma) among 20-64 year-olds in 2000. Case definition was based on the ICD-9-CM coding algorithm suggested by the Agency for Health Research and Quality - Prevention Quality Indicators. An area-based (census block) income index was used for each individual. All hospitalization rates were directly standardised for gender and age using the Italian population. Poisson regression analysis was performed to assess the relationship between income level (quintiles) and hospitalization rates (RR, 95% CI) separately for the selected conditions controlling for age, gender and city of residence.


Overall, the ACSC age-standardized rate was 26.1 per 10.000 inhabitants. All conditions showed a statistically significant socioeconomic gradient, with low income people being more likely to be hospitalized than their well off counterparts. The association was particularly strong for chronic obstructive pulmonary disease (level V low income vs. level I high income RR = 4.23 95%CI 3.37-5.31) and for congestive heart failure (RR = 3.78, 95% CI = 3.09-4.62). With the exception of asthma, males were more vulnerable to ACSC hospitalizations than females. The risks were higher among 45-64 year olds than in younger people.


The socioeconomic gradient in ACSC hospitalization rates confirms the gap in health status between social groups in our country. Insufficient or ineffective primary care is suggested as a plausible additional factor aggravating inequality. This finding highlights the need for improving outpatient care programmes to reduce the excess of unnecessary hospitalizations among poor people.