Access to this full-text is provided by Taylor & Francis.
Content available from International Journal of Chronic Obstructive Pulmonary Disease
This content is subject to copyright. Terms and conditions apply.
ORIGINAL RESEARCH
Factors Associated with Potentially Preventable
Hospitalizations for COPD Patients: A Qualitative
Analysis of Patient Perspectives
Liwen Ding
1,2
, Chu Chen
3
, Jianjian Wang
1,2
, Jay Pan
1,2
1
HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, People’s Republic of China;
2
Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, People’s Republic of
China;
3
School of Health Management, Fujian Medical University, Fuzhou, People’s Republic of China
Correspondence: Jay Pan, HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, No. 17, Section 3,
Ren Min Nan Road, Chengdu, 610041, People’s Republic of China, Email panjie.jay@scu.edu.cn; Chu Chen, Fujian Medical University, No. 1 Xuefu
North Road Da Xue Cheng Xin Qu, Minhou County, Fuzhou, 3501 22, People’s Republic of China, Email chuchen1988@fjmu.edu.cn
Purpose: Ambulatory Care Sensitive Conditions (ACSCs) refer to hospital encounters that could potentially be prevented with
improved primary care. Chronic Obstructive Pulmonary Disease (COPD) as one of the typical ACSCs, and its hospitalization is
considered potentially preventable through the quality primary care. However, the literature on factors inuencing Potentially
Preventable Hospitalization (PPH) has rarely been conducted from the patient perspective, especially in China. Our study aims to
explore the factors inuencing PPH for COPD patients.
Patients and Methods: This was a qualitative study. Twenty participants hospitalized by COPD were recruited from the healthcare
institutions in China. The semi-structured interviews were conducted from July to August 2022. The data were gathered and analyzed
systematically using thematic analysis.
Results: Patients’ experiences for PPH generated two main themes: environmental characteristics and personal characteristics. Sub-
themes included accessibility of healthcare resources, medical services capability, healthcare insurance policy, working environment,
disease cognition, health awareness, disease burden, income constrain, disease perception, negative emotions, and comorbidity.
Conclusion: Environmental characteristics and personal characteristics are factors associated with PPH for COPD patients. It is
important to enhance the medical service ability, improve the accessibility of healthcare resources and the health literacy of patients.
Keywords: preventable hospitalizations, ambulatory care-sensitive conditions, chronic obstructive pulmonary disease, patient
perspective, qualitative research
Introduction
Ambulatory Care Sensitive Conditions (ACSCs) refer to hospital encounters that could potentially be prevented with
improved primary care.
1
Chronic Obstructive Pulmonary Disease (COPD) characterized by chronic respiratory symp-
toms and airow obstruction, represents a preventable and treatable disease. As one of the typical ACSCs,
2
its manage-
ment heavily relies on early outpatient care services. Through the quality primary care, hospitalization of patients with
COPD is considered potentially preventable. However, according to the Global Initiative for Chronic Obstructive Lung
Disease (GOLD) case denition, 10.3% people aged 30–79 years had COPD worldwide in 2023,
3
leading to high
economic burden mainly caused by acute hospitalizations for exacerbations,
4
which make up the majority of medical
expenses. It is reported that COPD will cause a global economic loss of $4.326 trillion, with China having the highest
absolute economic burden of $1.363 trillion.
5
In China, COPD patients suffer from 0.5 to 3.5 acute exacerbations
per year,
6
the direct medical cost of COPD ranges from $72 to $3656 per capita per year.
7
To reduce the Potentially Preventable Hospitalization (PPH) rates and the resulting medical expenses, there has been
increasing attention devoted to understanding factors affecting PPH mostly used administrative data and found that, patient
International Journal of Chronic Obstructive Pulmonary Disease 2024:19 2719–2728 2719
© 2024 Ding et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php
and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work
you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For
permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).
International Journal of Chronic Obstructive Pulmonary Disease Dovepress
Open Access Full Text Article
Received: 31 July 2024
Accepted: 2 December 2024
Published: 12 December 2024
characteristics level, such as gender,
8–10
age,
11,12
education background,
13,14
ethnicity,
15,16
socioeconomic status,
17
and
healthcare insurance coverage,
18–20
and healthcare system level, including accessibility to primary care,
21
continuity of
care,
8,22
primary healthcare resourcing
23
professional characteristics of doctors,
24
associated with the increased risk of PPH.
However, most of the PPH studies cited above are from the developed countries and regions and most studies focused on
multiple ACSCs, which may exist some confounding factors. Although there are many similarities, there are also differences
inuencing PPH that may limit the applicability to Chinese context. Besides, the social variables outside the purview of
clinical medicine of PPH explored in these studies are limited, and there is little literature conducted from patient perspectives,
which helped to develop targeted interventions.
The aim of this study is to identify factors associated with PPH from patient experience in China because patient
perspective could provide a more holistic view of factors necessitating their hospitalizations and reecting specic
challenges in outpatient disease management, which provides valuable information for policy makers and clinical
professionals to understand the process of patients’ hospitalization and develop targeted intervention measures to reduce
the PPH rate and medical burden.
Methods
Study Design
The qualitative methodology was selected for this study, which could provide a better and in-depth understanding of the
research issues. According to the relevant factors affecting COPD hospitalization in the existing literature, a semi-
structured interview guide was formulated, including the demographic characteristics, behavior and living habits, health
management, and medical choice of patient. The semi-structured interview guide was improved after initial development.
A completed Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist is attached as Additional le 1.
Sample and Setting
PPH rates for COPD were relatively high in China,
25
especially in less developed areas, with decient healthcare
resources. Therefore, we selected Chishui city, located in Southwest China, and in the northernmost part of Guizhou
province, as our study area. The residents of Chishui city had a high incidence rate of COPD, ranking second in the cause
of death.
Participants who were hospitalized for COPD were recruited during hospitalization, from the healthcare institutions,
covering a three tiered health care delivery system, including village clinics, township health centers (THCs), and county
hospitals.
26
Participants hospitalized for COPD PPH were identied for the study admission following the Organization
for Economic Co-operation and Development (OECD) standards.
1
Inclusion criteria: Patient aged 15 and older; All non-maternal/non-neonatal hospital admissions with a principal
diagnosis code of COPD (including J40, J410, J411, J418, J42, J430, J431, J432, J438, J439, J440, J441, J448, J449).
Exclusion criteria: Cases where the patient passed away during hospital admission; Cases resulting from transfers
from another acute care institution; Obstetric hospitalizations; Same-day admissions.
Eligible subjects were recruited as follows: First, we contacted the attending physician of the hospitalized patients and
explained the purpose of this study to obtain the consent of the attending physician and help to recommend potential
qualied subjects to the research team. Second, the research team looked up the medical data of potential qualied
subjects and identied COPD PPH patients according to the inclusion and exclusion criteria. Last, through the
introduction of the attending physician, the informed consent of the patients participating in this study was obtained,
and then the interview was ofcially started. We rst contacted the attending physician who were respiratory physicians
because they knew more about the patient’s situation and could help the research team to nd qualied subjects more
quickly. With the help of the attending physician, patients are more likely to trust the research team. All participants were
able to express their views and experiences adequately.
Purposive sampling was used as it ensured access to COPD patients who had experience of PPH, and the selection
strategy was maximize the variation regarding age, residence, and complex social backgrounds. Twenty eligible patients
were recruited as participants by this method. A detailed description of participants is presented in Table 1.
https://doi.org/10.2147/COPD.S489520
DovePress
International Journal of Chronic Obstructive Pulmonary Disease 2024:19
2720
Ding et al Dovepress
Powered by TCPDF (www.tcpdf.org)
Data Collection
The interviews were conducted with each participant between July 2022 and August 2022. The semi-structured guide
was employed to take in-depth interviews and to collect data, which allowed participants to fully express their
experiences for PPH, their attitudes, and practices of disease management. Face-to-face interviews took place in the
patient ward and lasted 20–40 minutes. The researcher recorded the whole process of the interview with informed
consent and took eld notes. To achieve data saturation, data analysis was conducted while collecting data until no new
patient-reported factors emerged, the interviews ceased, we considered the thematic saturation was reached.
The study was conducted according to the Declaration of Helsinki. Ethical approval was granted from Ethics
Committee of Sichuan University (K2018087). All participants provided with written informed consent, including
consent for us to record and report anonymous data from interview.
Data Analysis
Interviews were transcribed conversationally and analyzed using thematic analysis proposed by Braun and Clarke.
27
Microsoft Word and Excel was used for analysis. The analysis process included the following steps: (1) after transcribed,
researchers re-read the transcripts to develop a general understanding of patients’ experiences and perform initial coding
line by line after identifying meaningful phrases; (2) the initial codes with the same or similar meaning were gathered to
form categories through interpretation of their experiences; (3) rened the categories to form themes, and established the
connections between themes and categories; (4) identied the main themes related to research question.
Results
After careful analysis from patient experiences, we summarized factors inuenced PPH into environmental character-
istics and personal characteristics (Figure 1). The environmental characteristics were the primary healthcare system,
health policy environment and working environment that affected PPH. Personal characteristics included economic
condition, cognition and behavior habits. Among them, disease perception was the most immediate factor that motivates
patients to seek medical services.
Table 1 Descriptive Characteristics of Participants
ID Gender Age Educational Background Reason for Hospitalizations Smoking History Method of Cooking
A01 Male 70 Higher and further education Acute exacerbation Ex-smoker Electricity
A02 Male 81 Primary school and lower Acute exacerbation Ex-smoker Electricity
A03 Male 74 Higher and further education Worsening symptoms Ex-smoker Electricity
A04 Male 82 Primary school and lower Acute exacerbation Ex-smoker Electricity
A05 Male 71 Primary school and lower Worsening symptoms Ex-smoker Electricity
A06 Male 67 Primary school and lower Worsening symptoms Ex-smoker Electricity
A07 Male 55 Primary school and lower Worsening symptoms Ex-smoker Electricity
A08 Male 66 Primary school and lower Acute exacerbation Ex-smoker Wood
A09 Male 59 Primary school and lower Worsening symptoms Current smoker Electricity
A10 Male 75 Primary school and lower Acute exacerbation Current smoker Electricity
A11 Female 68 Secondary school Worsening symptoms No smoking Wood
A12 Male 56 Secondary school Acute exacerbation Ex-smoker Electricity
A13 Male 52 Primary school and lower Worsening symptoms Ex-smoker Electricity
A14 Male 68 Primary school and lower Acute exacerbation Current smoker Wood
A15 Female 64 Primary school and lower Acute exacerbation Ex-smoker Wood
A16 Male 72 Primary school and lower Worsening symptoms Ex-smoker Wood
A17 Male 79 Secondary school Worsening symptoms No smoking Electricity
A18 Male 60 Secondary school Acute exacerbation Ex-smoker Used to burn wood
A19 Female 62 Secondary school Worsening symptoms No smoking Used to burn wood
A20 Female 61 Primary school and lower Acute exacerbation No smoking Used to burn wood
International Journal of Chronic Obstructive Pulmonary Disease 2024:19 https://doi.org/10.2147/COPD.S489520
DovePress
2721
Dovepress Ding et al
Powered by TCPDF (www.tcpdf.org)
Environmental Characteristics
Accessibility of Healthcare Resources
Medical resources included medical professionals, facilities, medicine, technology, services and other elements. Patients
reported that the medicine and equipment in the study area were inaccessible, and the human resources were less and of
low quality, which would have an impact on the treatment and management of patients and further affected PPH.
The THCs had few high-quality medical professionals and lack of medicine, many of the drugs could be bought in the
neighboring city, but we did not have them there …… I went to another city to see a doctor before and had a simple examination
to determine the cause of the disease, but we did not have this examination here. (A01)
Medical Services Capability
The medical services capability was affected by many factors including medical resources. Primary care professionals
played an important role of healthcare gatekeeper, the function of health education, and follow-up management.
However, in the study area, the number of medical professionals was relatively small and of relatively low quality,
with limited capability to deal with patients’ emergencies. Medicine supply was insufcient, while drug therapy was the
main treatment to maintain the stability of disease. These factors may affected the daily disease management and had the
Figure 1 Factors associated with PPH for COPD.
https://doi.org/10.2147/COPD.S489520
DovePress
International Journal of Chronic Obstructive Pulmonary Disease 2024:19
2722
Ding et al Dovepress
Powered by TCPDF (www.tcpdf.org)
possibility to generate inpatient service utilization. Furthermore, this may also affect patient medical choice, patients
might bypass the primary institutions with poor medical service capability and directly to the high-level hospitals.
We do not have many medicine here …… My condition is not very serious, but today is the eighth day of my hospitalization,
and the treatment effect is not very good. (A01)
The THCs could not treat my illness, and they did not have many medicines. if your condition is getting worse, you must come
to higher-level hospitals. (A07)
Healthcare Insurance Policy
The guarantee of healthcare insurance policy was vital for COPD patients since they need to take medicine to control the
development of disease for most of the time and avoid hospitalization caused by acute exacerbation. This study found
that the policy formulated by the health administration department had imperfect compensation mechanism, reected in
the limited types of medicine reimbursement and the small amount of reimbursement. Moreover, we also found the
policy publicity was not in place.
I had to buy medicine every month. In fact, the reimbursement lasted only half a year because the amount of reimbursement was
not enough for chronic condition patients. Some inhalations were not covered by insurance. (A01)
I had not heard of the reimbursement policy, and I did not know whether my condition met the criteria. (A07)
Working Environment
Some patients in the study were engaged in work that exposed to dust environment for a long time, while the dust
scattered in the air gradually damaged the function of the lung through the respiratory tract, and these participants did not
take any protective measures. These patients’ respiratory symptoms will become more and more serious, accompanied by
cold or poor disease self-management ability, and the possibility of hospitalization for acute attack will be greater.
I had worked for 11 years, there were no protective measures, rules and awareness of self-protection at that time. (A09)
It was worth mentioning that there were three participants suffered from pneumoconiosis and gradually developed
into COPD, accompanied by social vulnerability and low health literacy, leading to the utilization of inpatient services.
I did not have money to the hospital, and it was very expensive. Working outside and raising two children brought me a lot of
pressure, and now I feel tired and unable to work. I only took medicine when I felt uncomfortable I am still smoking now, I had
tried to quit before, but the more I quit, the greater the addiction. (A09)
Personal Characteristics
Disease Cognition
Many patients in the study had limited education level and lack of disease cognition. They had a vague understanding of
COPD, and some patients were not aware of the relationship between smoking and COPD, accordingly, they were unable
to take measures to control the further development of the disease.
I have not heard of getting vaccinated against inuenza or pneumonia. (A13)
I had a bad memory, and I could not remember how to manage the disease. The doctor told me not to smoke, but now I am still
smoking. I thought smoking and non-smoking had little impacts on the disease. (A10)
Health Awareness
Long-term, on-time, regular medication was an efcient way to control the progression of disease. However, some
patients automatically stopped taking medicine or forgot to take when the symptoms were alleviated or took it urgently
when the symptoms appeared. Therefore, the treatment was not effective.
International Journal of Chronic Obstructive Pulmonary Disease 2024:19 https://doi.org/10.2147/COPD.S489520
DovePress
2723
Dovepress Ding et al
Powered by TCPDF (www.tcpdf.org)
I would not take medicine if there were no symptoms. I only took it when the cough became severe. I would do some farm work
when I felt well, and I did not take the medicine with me, so I forget to use it. (A15)
The harm caused by unhealthy lifestyle behaviors such as second-hand smoke and the traditional fuel combustion
methods was more common. In rural areas, residents cooked or heated their home by burning biomass and fossil fuels,
such as wood and coal. However, due to the harmful gases, such as nitrogen monoxide and formaldehyde produced
during the combustion, as well as the particulate matter released during the process, long term exposed to an environment
lled with harmful gases and inhalable particles would result respiratory symptoms over time, and aggravation of
symptoms may lead to acute hospitalization. Most patients in the study were not aware of the impact on their health.
I did not use electricity in the past two years, and electricity was too expensive. My husband often smoked, and he used home-
made tobacco, and I could not stand the smell. (A20)
I used to burn wood to cook and feed pigs, and there was no chimney in my kitchen, so I always opened the door when I cook.
The development of the rural economy was sluggish, so we seldom used electronic power. (A16)
Disease Burden
Long term illness required signicant medical expenditures. Due to the economic burden of the disease, patients may
choose to invest less money in treatment, resulting in poor treatment effect and may lead to the onset of the disease.
I had applied for reimbursement policy successfully, but I still felt the economic burden was heavy. Because of the disease,
I could not go out to work, so I had no income, just stayed in my hometown, and I had to spend money to buy medicine every
month. (A12)
If the patient was the primary source of family income, it will bore the dual burden of disease and family.
I was diagnosed with silicosis at the age of 41, but I have been working all the time, because I had three children and the burden
on me was very heavy. (A07)
Income Constrain
Family disposable income was one of the inuencing factors of hospitalizations. The economic burden brought by
disease treatment reduced the quality of life and disposable income of patients and their families. Patients were affected
by the disease and left their jobs, resulting in a decrease in labor participation and productivity. Patients with low
disposable income might miss the maintenance treatment for disease, due to inability to afford the medical costs, leading
to utilization of inpatient services.
I have been ill for more than 10 years, and I could not do anything just stay at home. I had no nancial resources. (A13)
Economic factors could also affected the living behaviors and medical choice. Due to income constrained and limited
access to electricity resources, some rural patients still cooked by burning coal or wood.
I still burned wood, and the electricity was too expensive to use. The doctor asked me to transfer to a higher-level hospital, but
I did not have any money. (A15)
Disease Perception
Disease perception referred to a person’s awareness of the risk of developing a certain disease. If a person believed that
they are more likely to develop a disease, they were more willing to take proactive actions to seek health care services.
The patient stated that acute exacerbation caused by a cold, and worsening disease symptoms due to improper disease
management and weak health awareness were the main reasons for the hospitalization.
The main reason why I came to the hospital this time was that I had a cold, with coughing and wheezing. I knew it would be
troublesome if I did not press it down in time, so I came here for hospitalization treatment. (A01)
https://doi.org/10.2147/COPD.S489520
DovePress
International Journal of Chronic Obstructive Pulmonary Disease 2024:19
2724
Ding et al Dovepress
Powered by TCPDF (www.tcpdf.org)
Negative Emotions
COPD was characterized by long-term, recurrent, and complex etiology, patients felt strongly dominated by the disease,
and resulting negative emotions, which could also affect patients’ motivation to treat the disease and their self-
condence.
At my age, it was useless to get medical treatment, it was a waste anyway. Many of my colleagues died, it was an occupational
disease that hardly cured. Even if you had enough money, it could not be cured, one of my colleagues spent a lot of money on
surgery, and nally, he died. (A09)
Comorbidity
The presence of comorbidities was common in COPD patients, but if comorbidities could not be identied in a timely
manner, it had an impact on the diagnosis, treatment, and prognosis of patients.
My heart and cardiovascular problems also existed. One day I said to get the COVID-19 vaccine, and the doctor asked me if
I had high blood pressure, I said I had high blood pressure, and the doctor would not let me get vaccinated. I also had
osteoporosis. (A11)
Discussion
This study identied the factors associated with PPH for COPD patients in China using qualitative research method,
based on twenty participants’ experiences, which included environmental characteristics and personal characteristics.
These ndings are vital for providing valuable insights to reduce PPH and develop interventions.
Our study found that lack of healthcare resources and insufcient medical service capability in clinical practice fail to
meet the needs of patients. This nding aligns with the result of Wang et al.
28
Chishui city, which was originally
classied as a national poverty-stricken county and ofcially withdrew in October 2017, has seen signicant improve-
ment in economy and other areas. However, due to the limited development prospects, few medical professionals are
willing to stay at the grassroots level. This observation is consistent with the existing studies, which suggests that medical
professionals may be more inclined to practice in higher-level institutions and cities with better economic conditions.
29
Correspondingly, Li et al
30
provide evidence indicating that medical staff at primary level in China have insufcient
cognition of COPD, making them hardly to deal with patient emergencies. Our study also presented a negative example
that expanding the outpatient benet package can reduce PPH, which was proposed by Liu et al.
31
In terms of patient
experience, due to the limited population covered and reimbursement constraints of “Outpatient Chronic and Special
Diseases” policy, patients’ hospitalization behavior that could have been avoided through outpatient management.
Furthermore, access to care has an impact on disease management, which also conrms the previous ndings of our
research team using quantitative methods in the same region,
32,33
and this result may be attributed to the long distance
from patients’ residence to hospitals and inconvenient transportation services.
Our ndings also showed that knowledge affects patient’s work choice, disease cognition and health awareness
indirectly affects medical behavior, which is consistent with most studies.
34–37
First, patients in our study may be limited
by education level, they prefer to choose jobs that do not require high education level, such as quarries and construction,
and are at risk of occupational exposure. Studies have widely conrmed that occupational exposure to dust, gas, and
fumes
38
and various organic particles
39
are associated with COPD. Second, disease cognition is affected by multiple
factors. On the one hand, patients with high education pay more attention to their own health and are easier to understand
disease and health-related knowledge. On the other hand, the number of acute attacks and disease severity are related to
the disease cognition.
40
To reduce the number of hospitalizations and improve the quality of life, they may actively seek
health information. Last, consistent with our ndings, medication adherence and the use of solid fuels have proved to be
associated with COPD hospitalizations.
41–43
Possible reasons may be that most rural patients are inuenced by their
inherent beliefs, only take medicine once they experience recurrent cough, breathlessness, and other symptoms, and as
patients age increase, cognitive function and memory decline, so they may forget to take medicine. In addition, most of
International Journal of Chronic Obstructive Pulmonary Disease 2024:19 https://doi.org/10.2147/COPD.S489520
DovePress
2725
Dovepress Ding et al
Powered by TCPDF (www.tcpdf.org)
participants used to live in rural areas, they regard coal and wood as the main solid fuels,
44
and the cost of using
electricity is more expensive. They are not aware of the harm of toxic gases from fuel combustion to the respiratory tract.
This study found that acute exacerbation caused by colds are the immediate reasons of PPH. This nding is consistent
with the research by Tseng et al
45
and Johnston et al,
46
which reported that an over 30-fold increased risk of exacerbation
when colds were present compared to cold-free periods. One possible explanation may be that most participants in the
study are aged over 60, with deteriorated physiological functions, the risk of harmful effects of cold exposure increased.
Based on the research results, we suggest that improving accessibility of healthcare resources, enhancing the medical
capability of medical professionals through further education and skill learning in higher-level healthcare institutions are
needed. In addition, policy makers should consider the distance between patient’s residence, transportation services, and
healthcare providers when planning healthcare resources rationally, optimize spatial allocation of healthcare
resources.
47,48
Most importantly, healthcare professionals should focus on the education of patients and taking interven-
tion, using the unique advantage of hospital wards to conduct lectures on disease cognition, rehabilitation and manage-
ment, and establishing a connection between healthcare professionals and patients. It is worth mentioning that
vaccination is currently an effective way to prevent colds and respiratory infections, which could also reduce the
likelihood of deterioration in COPD patients.
49–52
Therefore, for COPD patients, particularly the elderly, keeping
warm and receiving vaccination annually should be recommended.
This study was designed and conducted following qualitative methodology, and it was the rst article to explore the
PPH-related factors from the patient perspectives in China. It was also added in-depth detailed information to the
currently limited data on PPH-related factors for COPD. Compared to the quantitative method, focusing on the social and
behavioral background context of patient experiences may help to explain the failure of disease management in
preventing hospitalizations through interviews. Most importantly, many of the factors that patients self-reported, such
as lack of knowledge and negative emotions, are unlikely to appear in the hospital administrative data. Although the
saturation of sample information was achieved in the study, there are also some limitations. The face-to-face interviews
were based on patients’ self-reported experiences, and the recall of disease progression and hospitalization experiences
may be affected by recall bias. In addition, the ndings only represent the experiences of the study population, and the
study should be replicated in different cities in the future. Given the inherent limitations of qualitative research, we will
develop a questionnaire based on the results of this study in future research to further verify the relationship between
these factors and PPH in a larger population.
Conclusion
Environmental characteristics and personal characteristics are factors associated with PPH, and in personal character-
istics, disease perception is the immediate reason of PPH. The signicant barriers of preventing PPH are patient cognition
and accessibility of healthcare resources at primary level. Therefore, healthcare providers should teach patients the
process of occurrence and development of the disease, how to respond when it occurs, relevant knowledge of heath
management, regularly follow-up to check patient’s condition and medication, and make adjustment timely. Healthcare
professionals should also improve the capability of clinical practice. By implementing these strategies, healthcare
providers can better handle and manage patients with COPD at the primary level.
Acknowledgments
This work was supported by China Postdoctoral Science Foundation [2020M683298]; Fujian Medical University
[XRCZX2021007].
Disclosure
The authors report no conicts of interest in this work.
References
1. Agency for Healthcare Research and Quality. Prevention quality indicators. Available from: http://www.qualityindicators.ahrq.gov/modules/pqi_
resources.aspx. Accessed June 5, 2023.
https://doi.org/10.2147/COPD.S489520
DovePress
International Journal of Chronic Obstructive Pulmonary Disease 2024:19
2726
Ding et al Dovepress
Powered by TCPDF (www.tcpdf.org)
2. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274(4):305–311. doi:10.1001/
jama.1995.03530040033037
3. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2023 REPORT). Available from: https://
goldcopd.org. Accessed June 5, 2023.
4. Lopez-Campos JL, Tan W, Soriano JB. Global burden of COPD. Respirology. 2016;21(1):14–23. doi:10.1111/resp.12660
5. Chen SM, Kuhn M, Prettner K, et al. The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in
2020–50: a health-augmented macroeconomic modelling study. Lancet Glob Health. 2023;11(8):e1183–e1193. doi:10.1016/S2214-109X(23)00217-6
6. Expert group on management of acute exacerbation of chronic obstructive pulmonary disease. Expert consensus on acute exacerbation of chronic
obstructive pulmonary disease in the People’s Republic of China (revision in 2023). Int J Respir. 2023;43(2):132–149. doi:10.3760/cma.j.
cn131368-20221123-01066
7. Zhu B, Wang Y, Ming J, et al. Disease burden of COPD in China: a systematic review. Int J Chron Obstruct Pulmon Dis. 2018;13:1353–1364.
doi:10.2147/COPD.S161555
8. Nyweide DJ, Anthony DL, Bynum JPW, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med.
2013;173(20):1879–1885. doi:10.1001/jamainternmed.2013.10059
9. Rizza P, Bianco A, Pavia M, et al. Preventable hospitalization and access to primary health care in an area of southern Italy. BMC Health Serv Res.
2007;7:134. doi:10.1186/1472-6963-7-134
10. Paul MC, Dik JWH, Hoekstra T, et al. Admissions for ambulatory care sensitive conditions: a national observational study in the general and COPD
population. Eur J Public Health. 2019;29(2):213–219. doi:10.1093/eurpub/cky182
11. Quinn N, Gupta N. Income inequalities in the risk of potentially avoidable hospitalization and readmission for chronic obstructive pulmonary
disease: a population data linkage analysis. Int J Popul Data Sci. 2020;5(1). doi:10.23889/ijpds.v5i3.1388
12. Botelho JF, Portela MC. Risk of misinterpretation of trends in hospital admissions for primary care sensitive conditions in local contexts: itaborai,
Rio de Janeiro State, Brazil, 2006–2011. Cadernos De Saude Publica. 2017;33(3). doi:10.1590/0102-311X00050915
13. Thygesen LC, Christiansen T, Garcia-Armesto S, et al. Potentially avoidable hospitalizations in ve European countries in 2009 and time trends
from 2002 to 2009 based on administrative data. Euro J Public Health. 2015;25:35–43. doi:10.1093/eurpub/cku227
14. Van Der Pol M, Olajide D, Dusheiko M, et al. The impact of quality and accessibility of primary care on emergency admissions for a range of chronic
ambulatory care sensitive conditions (ACSCs) in Scotland: longitudinal analysis. BMC Fam Pract. 2019;20. doi:10.1186/s12875-019-0921-z
15. Laditka JN, Laditka SB. Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA. Ethnicity Health.
2006;11(3):247–263. doi:10.1080/13557850600565640
16. Howard DL, Hakeem FB, Njue C, et al. Racially disproportionate admission rates for ambulatory care sensitive conditions in North Carolina.
Public Health Rep. 2007;122(3):362–372. doi:10.1177/003335490712200310
17. Trachtenberg AJ, Dik N, Chateau D, et al. Inequities in ambulatory care and the relationship between socioeconomic status and respiratory
hospitalizations: a population-based study of a Canadian City. Ann Fam Med. 2014;12:402–407. doi:10.1370/afm.1683
18. Bindman AB, Chattopadhyay A, Auerback GM. Interruptions in Medicaid coverage and risk for hospitalization for ambulatory care-sensitive
conditions. Ann Intern Med. 2008;149(12):854. doi:10.7326/0003-4819-149-12-200812160-00004
19. Bergamo C, Juarez Colunga E, Capp R. Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive
condition conditions. Am J Emerg Med. 2016;34(5):820–824. doi:10.1016/j.ajem.2016.01.023
20. Wood SM, Yue ML, Kotsis SV, et al. Preventable hospitalization trends before and after the affordable care act. AJPM Focus. 2022:100027.
doi:10.1016/j.focus.2022.100027
21. Marques AP, Montilla DER, Almeida WD, et al. Hospitalization of older adults due to ambulatory care sensitive conditions. Rev Saude Publica.
2014;48:817–826. doi:10.1590/S0034-8910.2014048005133
22. Lin IP, Wu SC. Effects of long-term high continuity of care on avoidable hospitalizations of chronic obstructive pulmonary disease patients. Health
Policy. 2017;121(9):1001–1007. doi:10.1016/j.healthpol.2017.06.010
23. Zhao X, Zhang Y, Yang Y, et al. Diabetes-related avoidable hospitalizations and its relationship with primary health care resourcing in China: a
cross-sectional study from Sichuan Province. Health Soc Care Comm. 2022;30:e1143–e1156. doi:10.1111/hsc.13522
24. O’malley AS, Pham HH, Schrag D, et al. Potentially avoidable hospitalizations for COPD and pneumonia – the role of physician and practice
characteristics. Med Care. 2007;45(6):562–570. doi:10.1097/MLR.0b013e3180408df8
25. Chen S, Fu H, Jian W. Trends in avoidable hospitalizations in a developed city in eastern China: 2015 to 2018. BMC Health Serv Res. 2022;22:856.
doi:10.1186/s12913-022-08275-w
26. Wang X, Yang H, Duan Z, et al. Spatial accessibility of primary health care in China: a case study in Sichuan Province. Soc Sci Med.
2018;209:14–24. doi:10.1016/j.socscimed.2018.05.023
27. Braun V, Clarke V. Conceptual and design thinking for thematic analysis, qualitative. Psychology. 2022;9(1):3. doi:10.1037/qup0000196
28. Wang GR, Jiang M, Tong XH, et al. Situation analysis of township health workers in poor rural counties. Chin Primary Health Care. 2002;5:27–29.
29. Meng Q, Yuan J, Jing L, et al. Mobility of primary health care workers in China. Hum Resour Health. 2009;7:24. doi:10.1186/1478-4491-7-24
30. Li S, Jia C, Fang F, et al. Investigation on cognition of chronic obstructive pulmonary disease(COPD) among doctors in 18 areas of China. Chin
J Health Educ. 2020;36(3):195–199. doi:10.16168/j.cnki.issn.1002-9982.2020.03.001
31. Liu HR, Chen SY, Zhang LY, et al. Expanding outpatient benets package can reduce diabetes-related avoidable hospitalizations. Front Public
Health. 2023;11:964789. doi:10.3389/fpubh.2023.964789
32. Chen T, Pan J. The effect of spatial access to primary care on potentially avoidable hospitalizations of the elderly: evidence from Chishui City,
China. Soc Indic Res. 2022;160:645–665. doi:10.1007/s11205-020-02413-9
33. Chen L, Chen T, Lan T, et al. The contributions of population distribution, healthcare resourcing, and transportation infrastructure to spatial
accessibility of health care. INQUIRY J Health Car. 2023;60. doi:10.1177/00469580221146041
34. Wang R, Zhang W, Li Y, et al. Evaluation of risk factors for chronic obstructive pulmonary disease in the middle-aged and elderly rural population
of northeast China using logistic regression and principal component analysis. Risk Manag Healthc Policy. 2022;15:1717–1726. doi:10.2147/
RMHP.S376546
35. Tiemensma J, Gaab E, Voorhaar M, et al. Illness perceptions and coping determine quality of life in COPD patients. Int J Chron Obstruct Pulmon
Dis. 2016;11:2001–2007. doi:10.2147/COPD.S109227
International Journal of Chronic Obstructive Pulmonary Disease 2024:19 https://doi.org/10.2147/COPD.S489520
DovePress
2727
Dovepress Ding et al
Powered by TCPDF (www.tcpdf.org)
36. Antoniu SA. Adherence to inhaled therapy in COPD: effects on survival and exacerbations. Expert Rev Pharmacoecon Outcomes Res.
2010;10:115–117. doi:10.1586/erp.10.10
37. Gershon AS, Warner L, Cascagnette P, et al. Lifetime risk of developing chronic obstructive pulmonary disease: a longitudinal population study.
Lancet. 2011;378(9795):991–996. doi:10.1016/S0140-6736(11)60990-2
38. Mehta AJ, Miedinger D, Keidel D, et al. Occupational exposure to dusts, gases, and fumes and incidence of chronic obstructive pulmonary disease
in the Swiss Cohort study on air pollution and lung and heart diseases in adults. Am J Respir Crit Care Med. 2012;185:1292–1300. doi:10.1164/
rccm.201110-1917OC
39. Grahn K, Gustavsson P, Andersson T, et al. Occupational exposure to particles and increased risk of developing chronic obstructive pulmonary
disease (COPD): a population-based cohort study in Stockholm, Sweden. Environ Res. 2021;200:111739. doi:10.1016/j.envres.2021.111739
40. Baiardini I, Rogliani P, Santus P, et al. Disease awareness in patients with COPD: measurement and extent. Int J Chron Obstruct Pulmon Dis.
2018;14(17):1–11. doi:10.2147/COPD.S179784
41. Chan KH, Kurmi OP, Bennett DA, et al. Solid fuel use and risks of respiratory diseases. A cohort study of 280, 000 Chinese never-smokers. Am
J Respir Crit Care Med. 2019;199(3):352–361. doi:10.1164/rccm.201803-0432OC
42. Raju S, Keet CA, Paulin LM, et al. Rural residence and poverty are independent risk factors for chronic obstructive pulmonary disease in the United
States. Am J Respir Crit Care Med. 2019;199(8):961–969. doi:10.1164/rccm.201905-0974LE
43. Li J, Qin C, Lv J, et al. Solid fuel use and incident COPD in Chinese adults: ndings from the China Kadoorie Biobank. Environ Health Perspect.
2019;127(5):57008. doi:10.1289/EHP2856
44. Tang X, Liao H. Energy poverty and solid fuels use in rural China: analysis based on national population census. Energy Sustain Dev.
2014;23:122–129. doi:10.1016/j.esd.2014.08.006
45. Tseng CM, Chen YT, Ou SM, et al. The effect of cold temperature on increased exacerbation of chronic obstructive pulmonary disease:
a nationwide study. PLoS One. 2013;8:e57066. doi:10.1371/journal.pone.0057066
46. Johnston NW, Olsson M, Edsbäcker S, et al. Colds as predictors of the onset and severity of COPD exacerbations. Int J Chron Obstruct Pulmon
Dis. 2017;12:839–848. doi:10.2147/COPD.S127146
47. Pan J, Deng Y, Yang Y, et al. Location-allocation modelling for rational health planning: applying a two-step optimization approach to evaluate the
spatial accessibility improvement of newly added tertiary hospitals in a metropolitan city of China. Soc Sci Med. 2023;338:116296. doi:10.1016/j.
socscimed.2023.116296
48. Zhang Y, Yang H, Pan J. Gaining from rational health planning: spatial reallocation of top-tier general hospital beds in China. Comput Ind Eng.
2021;157:107344. doi:10.1016/j.cie.2021.107344
49. British Thoracic Society. IMPRESS guide to the relative value of COPD interventions. British Thoracic Society Reports, 2012. Available from:
https://www.networks.nhs.uk/nhs-networks/impressimproving-and-integrating-respiratory. Accessed June 5, 2023.
50. Poole PJ, Chacko E, Wood-Baker RW, et al. Inuenza vaccine for patients with chronic obstructive pulmonary disease. Cochrane Database Syst
Rev. 2006;1:CD002733. doi:10.1002/14651858.CD002733.pub2
51. Walters JA, Tang JN, Poole P, et al. Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease. Cochrane
Database Syst Rev. 2017;1:CD001390. doi:10.1002/14651858.CD001390.pub4
52. Wongsurakiat P, Maranetra KN, Wasi C, et al. Acute respiratory illness in patients with COPD and the effectiveness of inuenza vaccination:
a randomized controlled study. Chest. 2004;125:2011–2020. doi:10.1378/chest.125.6.2011
International Journal of Chronic Obstructive Pulmonary Disease Dovepress
Publish your work in this journal
The International Journal of COPD is an international, peer-reviewed journal of therapeutics and pharmacology focusing on concise rapid reporting
of clinical studies and reviews in COPD. Special focus is given to the pathophysiological processes underlying the disease, intervention programs,
patient focused education, and self management protocols. This journal is indexed on PubMed Central, MedLine and CAS. The manuscript
management system is completely online and includes a very quick and fair peer-review system, which is all easy to use. Visit http://www.
dovepress.com/testimonials.php to read real quotes from published authors.
Submit your manuscript here: https://www.dovepress.com/international-journal-of-chronic-obstructive-pulmonary-disease-journal
DovePress International Journal of Chronic Obstructive Pulmonary Disease 2024:19
2728
Ding et al Dovepress
Powered by TCPDF (www.tcpdf.org)
