Geographic variation in potentially preventable hospitalisations in Indonesia: a multilevel analysis using National Health Insurance Sample Data

Abstract

Objectives: Indonesian data on potentially preventable hospitalisations (PPH), a widely used indicator for measuring primary healthcare (PHC) quality, are lacking. This study aimed to describe Indonesia’s PPH rates and to quantify variation in PPH across districts/cities and their associations with individual sociodemographic characteristics. Design and setting: Cross-sectional study conducted in Indonesia using the 2023 National Health Insurance Sample Data. Participants: Sample of 2.32 million individuals, representing 266.85 million national health insurance—Jaminan Kesehatan Nasional (JKN)—enrolees. Outcome measures: PPH overall and by type: vaccine-preventable, acute and chronic. Methods: We quantified crude and age-standardised PPH rates (overall and by type) per 10 000 JKN enrolees. We applied multilevel negative binomial regression and estimated: (1) median rate ratios (MRRs) to quantify variation in PPH across districts/cities, unadjusted and adjusted for sociodemographic characteristics and (2) incidence rate ratios (IRRs) to quantify associations between PPH and sociodemographic characteristics. Results: There were 4.83 million overall PPH in 2023, an overall rate of 180.9 per 10 000 JKN enrolees (acute: 94.8, chronic: 93.6, vaccine-preventable: 2.8). Overall PPH rates were generally highest in districts/cities in Java-Bali, Sulawesi, Sumatera and Kalimantan, lower in Nusa Tenggara and Maluku and lowest in Papua. Variation in PPH across districts/cities was similar for all PPH types (MRRs overall: 1.62, vaccine-preventable: 1.83, acute: 1.72, chronic: 1.53) and persisted after adjusting for sociodemographic characteristics (MRRs of 1.52, 1.82, 1.61, 1.41, respectively). After adjustment, PPH rates were higher in the older age groups, particularly chronic (eg, compared with 25−34 years, adjusted IRRs for 55−64 years=11.94, 95% CI 11.15 to 12.79; 65−74 years=13.63, 12.67 to 14.67); the youngest age group (0−14 years) particularly vaccine-preventable (IRR 5.22, 95% CI 4.02 to 6.79) and acute (IRR 5.46, 95% CI 5.19 to 5.74); among those married or divorced compared with single (acute, chronic and overall PPH: IRRs range from 1.20 to 1.39 for married and from 1.42 to 1.69 for divorced individuals) and among non-subsidised compared with subsidised JKN enrolees (all PPH types: IRRs range from 1.25 to 1.68). Conclusions: PPH varied across districts/cities as well as by sociodemographic characteristics. While PPH has potential for measuring PHC quality in Indonesia, context-specific interpretation is required as lower PPH may reflect limited accessibility to hospital care rather than better PHC quality. Show more