Perceived Stress, Multimorbidity, and Risk for Hospitalizations for Ambulatory Care-sensitive Conditions: A Population-based Cohort Study

Med Care. 2017 Feb;55(2):131-139. doi: 10.1097/MLR.0000000000000632.


Background: Psychiatric disorders are associated with an increased risk for ambulatory care-sensitive condition (ACSC)-related hospitalizations, but it remains unknown whether this holds for individuals with nonsyndromic stress that is more prevalent in the general population.

Objectives: To determine whether perceived stress is associated with ACSC-related hospitalizations and rehospitalizations, and posthospitalization 30-day mortality.

Research design and measures: Population-based cohort study with 118,410 participants from the Danish National Health Survey 2010, which included data on Cohen's Perceived Stress Scale, followed from 2010 to 2014, combined 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.

Results: Being in the highest perceived stress quintile was associated with a 2.13-times higher ACSC-related hospitalization risk (95% CI, 1.91, 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, 1.67) after fully adjusting for multimorbidity and socioeconomic factors. Individuals with above reference stress levels experienced 1703 excess ACSC-related hospitalizations (18% of all). 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 insignificantly increased adjusted risk (95% CI, 0.79, 2.00) for ACSC rehospitalizations and a 1.43-times increased adjusted risk (95% CI, 1.13, 1.81) of mortality within 30 days of admission.

Conclusions: Elevated perceived stress levels are associated with increased risk for ACSC-related hospitalization and poor short-term prognosis.

MeSH terms

  • Adult
  • Aged
  • Comorbidity
  • Denmark / epidemiology
  • Female
  • Health Behavior
  • Hospitalization / statistics & numerical data*
  • Humans
  • Life Style
  • Male
  • Middle Aged
  • Perception
  • Risk Factors
  • Socioeconomic Factors
  • Stress, Psychological / epidemiology*
  • Stress, Psychological / psychology*