Are perceived stress and multimorbidity associated with an increased risk of hospitalizations for ambulatory care-sensitive conditions?

Talk Code: 
Anders Prior
Mogens Vestergaard, Dimitry S Davydow, Karen Kjær Larsen, Anette Riisgaard Ribe, Morten Fenger-Grøn
Author institutions: 
Aarhus University, Department of Psychiatry and Behavioral Sciences


Ambulatory care-sensitive conditions (ACSCs) should be treated mainly in primary care, and hospitalization for these common and costly conditions is potentially preventable. Psychiatric disorders are associated with an increased risk for ACSC-related hospitalizations, but it remains unknown whether this holds for individuals with non-syndromic stress which is more prevalent in the general population. Objective: To determine whether perceived stress is associated with hospitalizations and rehospitalizations for ambulatory care-sensitive conditions (ACSCs) and post-hospitalization 30-day mortality.


We performed a population-based cohort study with 118,410 participants from the Danish National Health Survey 2010. Participants were followed from 2010 to 2014, and we combined survey data on Cohen's Perceived Stress Scale and lifestyle with individual-level national register data on hospitalizations and mortality. Multimorbidity was assessed using health register information on diagnoses and drug prescriptions within 39 condition categories. Our primary outcome was the number of ACSC-related hospitalizations. Secondary outcomes included the number of ACSC-related rehospitalizations and all-cause mortality within 30 days after hospitalization.


Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91 to 2.38) versus being in the lowest stress quintile after adjusting for age, sex, follow-up time, and predisposing conditions. The associated risk attenuated to 1.48 (95% CI, 1.32 to 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1,703 excess hospitalizations for ACSCs (18% of all ACSC-related hospitalizations). A dose-response relationship was observed between perceived stress and the ACSC-related hospitalization rate regardless of multimorbidity status. Being in the highest stress quintile was associated with a 1.26-times increased adjusted risk (95% CI, 0.79 to 2.00) for ACSC-rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13 to 1.81) of mortality within 30 days of hospital admission.


Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis. The implication for healthcare systems could be a stronger focus on mental health in guidelines and risk stratification. Further research is needed to determine if primary care-based stress reduction interventions could prevent these costly events and improve patient outcomes.

Submitted by: 
Anders Prior
Funding acknowledgement: 
Supported by an unrestricted grant (Grant Number: R155-2012-11280) from the Lundbeck Foundation (MEPRICA) and the Central Denmark Region Foundation for Primary Health Care Research. The Danish Health Profile 2010 was funded by the Capital Region of Denmark, Region Zealand, the Region of Southern Denmark, the Central Denmark Region, the North Denmark Region, the Danish Ministry of Interior and Health, and the Danish National Institute of Public Health at University of Southern Denmark.