Trends and epidemiological profile of preventable hospitalizations in Honduras (2014 - 2024): An 11-year analysis of ambulatory care sensitive conditions

This 11-year retrospective analysis of Honduran hospital data reveals that Ambulatory Care Sensitive Conditions account for 13.6% of all hospitalizations, with rates fluctuating significantly due to the pandemic and disproportionately affecting children, the elderly, and patients with chronic noncommunicable diseases, thereby highlighting critical gaps in primary health care performance.

The Gist

Imagine the healthcare system as a massive, complex plumbing network for a city. Ideally, small leaks (minor illnesses) should be fixed quickly at the source by a handy plumber (the Primary Care Doctor) before they turn into a flooded basement requiring an emergency crew (the Hospital).

This paper is a report card on how well the "handymen" in Honduras are doing their job between 2014 and 2024. It looks at Ambulatory Care Sensitive Conditions (ACSCs). Think of these as the "leaks" that should have been fixed at home but ended up flooding the basement anyway.

Here is the story of what the researchers found, broken down simply:

1. The Big Picture: A Lot of Preventable Floods

The researchers looked at over 4 million hospital visits in Honduras. They found that 13.6% of all those visits were for conditions that could have been prevented with better primary care.

• The Analogy: Imagine a city of 100 people. In Honduras, about 14 of them ended up in the hospital for things that a quick, cheap visit to a local clinic could have stopped.
• The Cost: These preventable visits weren't just a nuisance; they were expensive and dangerous. Patients stayed in the hospital longer (about 5 days vs. 4 days) and were more likely to die while there compared to people who went in for things that couldn't be prevented (like a car accident or advanced cancer).

2. Who Got Sick? The Two Extremes

The "leaks" weren't happening randomly. They were concentrated at the two ends of the age spectrum:

• The Little Ones (Under 5): Mostly suffering from infections like stomach bugs and pneumonia. It's like the plumbing in a nursery is fragile and needs constant attention.
• The Elders (Over 60): Mostly suffering from chronic "rust" on the pipes—diabetes, high blood pressure, and heart issues.
• The Main Culprit: Diabetes was the single biggest cause of these preventable hospitalizations. It's as if the sugar in the blood is slowly corroding the pipes, and without regular maintenance, the system bursts.

3. The Rollercoaster Ride (2014–2024)

The trends over the last decade look like a rollercoaster with three distinct drops and climbs:

• Phase 1: The Slow Climb (2014–2018): The number of preventable hospitalizations was slowly creeping up. The "handymen" were getting a bit overwhelmed.
• Phase 2: The Sudden Drop (2018–2021): Then, everything crashed. Hospital visits for these conditions plummeted.
  • Why? First, a massive Dengue fever outbreak in 2019 clogged the system. Then, the COVID-19 pandemic hit. People were terrified to go to the doctor, and the hospitals were so busy fighting the virus that they couldn't see people with diabetes or asthma. It was like the whole city stopped calling the plumber because everyone was hiding in their bunkers.
• Phase 3: The Bounce Back (2021–2024): As the pandemic eased, the numbers shot back up—so fast that the rate of increase was five times faster than the slow climb at the start.
  • The Reality: This wasn't a good thing. It meant that all the "leaks" that were ignored during the pandemic finally burst. The system was flooded with delayed care.

4. The "Why" Behind the Floods

The paper suggests that the Honduran health system is like a house with a weak foundation.

• Funding: The government spends very little on health (only 3.5% of the country's total money).
• Access: Many people have to pay out of their own pockets to see a doctor, which stops them from going until it's an emergency.
• The Result: People wait too long. A simple headache becomes a stroke; a minor infection becomes pneumonia. By the time they get to the hospital, the damage is done.

5. The Takeaway: Fix the Handymen, Not Just the Basement

The authors conclude that you can't just keep hiring more emergency crews (hospitals) to fix the floods. You have to fix the Primary Care system.

• The Solution: We need to empower the local "handymen" (doctors and nurses in the community) with better tools, more money, and better training.
• The Goal: Catch the diabetes and infections early, before they turn into a crisis. This would save lives, save money, and stop the "floods" in the first place.

In short: Honduras has a lot of preventable hospitalizations, mostly driven by diabetes and infections in the very young and very old. The system took a hit during the pandemic, and now it's struggling to catch up with all the care that was delayed. The fix isn't building more hospitals; it's making sure the local clinics work better so people never need to go to the hospital in the first place.

Technical Summary

1. Problem Statement

Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which effective and timely primary health care (PHC) can prevent the need for hospitalization. Consequently, ACSC hospitalization rates serve as a critical proxy indicator for the accessibility, quality, and resolution capacity of a country's primary care system.

Despite the relevance of this metric, there is a significant knowledge gap regarding ACSCs in Central America. Most existing data comes from high-income nations or specific settings in Latin America (e.g., Costa Rica, El Salvador), leaving a lack of nationally representative evidence for Honduras. Furthermore, the impact of the COVID-19 pandemic and the 2019 Dengue outbreak on healthcare utilization patterns in Honduras remains unquantified. This study aims to fill these gaps by analyzing the burden, epidemiological profile, and temporal trends of ACSC hospitalizations in Honduras over an 11-year period.

2. Methodology

• Study Design: A retrospective observational study utilizing national administrative hospital discharge data.
• Data Source: The National Hospital Discharge Database managed by the Health Statistics Department of the Honduran Ministry of Health (MoH). The dataset covers all 33 public hospitals in the MoH subsystem.
• Timeframe: January 1, 2014, to December 31, 2024 (11 years).
• Study Population:
  • Initial records: 4,151,121 hospital care records.
  • Inclusion: Patients with at least one day of stay in a public hospital.
  • Exclusion: Primary care level services, observation services, stays >365 days, and records with missing key variables (diagnosis/sex).
  • Final Analyzed Sample: 4,023,944 hospitalizations (representing 84.7% of all discharges reported by the MoH and Social Security Institute subsystems).
• Definitions & Classification:
  • ACSC Definition: Based on the PAHO 2020–2025 Strategic Plan and Alfradique et al., utilizing 20 diagnostic groups defined by 143 specific ICD-10 codes.
  • Categorization: Hospitalizations were split into ACSCs and non-ACSCs. ACSCs were further grouped into three broad categories: Preventable Infectious Diseases, Noncommunicable Diseases (NCDs), and Maternal, Child, and Nutritional Conditions (MCNC).
• Statistical Analysis:
  • Rates: Calculated as sex-age-standardized rates per 10,000 inhabitants using the 2019 Honduran population as the standard reference.
  • Trend Analysis: Joinpoint Regression Models were used to identify temporal segments, calculating Annual Percent Changes (APC) and Average Annual Percent Changes (AAPC).
  • Comparisons: Chi-square tests for categorical variables (fatality rates) and Wilcoxon rank-sum tests for continuous variables (Length of Stay).
  • Software: RStudio (v4.5.2) and Joinpoint Regression Program (v6.0.1).

3. Key Contributions

• First National Assessment: This is the first comprehensive study to quantify ACSC hospitalizations across the entire Honduran public health network over a decade.
• Pandemic Impact Analysis: It provides a granular analysis of how the 2014–2024 period, specifically the pre-pandemic, pandemic (2020–2021), and post-pandemic phases, affected preventable hospitalization trends.
• Epidemiological Profiling: It details the specific burden of ACSCs across different age groups, sexes, and disease categories, highlighting the dual burden of infectious diseases and NCDs.
• Policy-Relevant Metrics: By linking ACSC rates to Length of Stay (LOS) and in-hospital fatality, the study quantifies the clinical and economic burden of preventable admissions.

4. Key Results

Overall Burden

• Total ACSCs: 547,486 hospitalizations, representing 13.6% of all hospital admissions.
• Standardized Rate: The overall sex-age-standardized rate was 54.1 per 10,000 inhabitants.
• Clinical Impact: ACSC admissions were associated with longer LOS (4.9 days vs. 3.9 days for non-ACSCs; p<0.001) and higher in-hospital fatality rates (2.4% vs. 1.7%; p<0.001).

Temporal Trends (Joinpoint Regression)

The study identified three distinct temporal segments:

1. 2014–2018: A non-significant increase in rates (APC: 2.7%).
2. 2018–2021: A sharp, significant decline (APC: -17.8%). This period encompasses the 2019 Dengue emergency and the onset of the COVID-19 pandemic.
3. 2021–2024: A significant rebound (APC: 15.9%), though rates remained below pre-pandemic levels.

• Overall Trend: The Average Annual Percent Change (AAPC) for the entire period was -0.4% (non-significant).

Epidemiological Profile

• Disease Categories: Noncommunicable Diseases (NCDs) were the primary driver, accounting for 56.8% of ACSC cases. Diabetes mellitus was the leading specific cause.
• Age Distribution: ACSCs were concentrated at the extremes of the life course:
  • Children <5 years: 27.7% of cases (driven by infectious gastroenteritis and lower airway diseases).
  • Adults ≥60 years: 29.9% of cases (driven by NCDs like diabetes and hypertension).
• Fatality by Age: The highest fatality rate (14.7%) was observed in the >80 age group due to cerebrovascular disease. NCDs generally exhibited 2–4 times higher fatality rates than infectious conditions.

Pandemic Effects

• During the pandemic (2020–2021), the proportion of ACSCs dropped to 10.8% (standardized rate: 35.6/10,000), likely due to reduced healthcare-seeking behavior and resource reallocation.
• Post-pandemic (2022–2024), rates rebounded to 14.3% (standardized rate: 50.7/10,000), suggesting a "pent-up" demand and worsening of chronic conditions.

5. Significance and Implications

• PHC Performance Indicator: The high proportion of ACSC hospitalizations (13.6%) indicates persistent gaps in access to and quality of primary care in Honduras. It suggests that a significant number of admissions could be avoided with better outpatient management.
• Health System Resilience: The sharp decline and subsequent rebound highlight the fragility of the health system during crises. The 2018 joinpoint suggests that the 2019 Dengue outbreak may have already strained the system before the pandemic.
• Targeted Interventions:
  • Chronic Disease Management: Strengthening PHC for diabetes and hypertension is critical, as NCDs drive the majority of the burden and mortality.
  • Vulnerable Populations: Interventions must be age-specific, focusing on preventive care for children (infectious diseases) and integrated care for the elderly (NCDs).
• Regional Context: While Honduras' ACSC rate (14.9% standardized) is lower than the Latin American regional average (17.4%), it remains substantially higher than high-income countries (e.g., Spain/UK at ~4.5–11%), underscoring the need for structural improvements in primary care organization and financing.

Conclusion: The study concludes that while the pandemic temporarily reduced ACSC admissions, the subsequent rebound and the dominance of NCDs necessitate a strategic strengthening of Primary Health Care in Honduras to improve health system efficiency, equity, and resilience.