Impact of the COVID-19 Pandemic on Healthcare Utilization among Medically Underserved Patients with Ambulatory Care Sensitive Conditions.

338 Background: OP-35 is a publicly reported quality metric aimed at reducing preventable emergency department (ED) visits and hospitalizations in patients with cancer on chemotherapy. During the COVID-19 surge, one academic medical center opened the Respiratory Emergent Evaluation Service (REES) Unit, an urgent care clinic for patients with cancer and symptoms of COVID-19. In addition to preventing potential COVID-19 exposures in the clinic, this oncology-staffed urgent care evaluated patients who may have otherwise presented to the ED. We investigated the association between the REES urgent care clinic and patient ED evaluations for OP-35 diagnoses. Methods: This single center retrospective analysis included patients with cancer receiving infusion and oral chemotherapy who presented to the ED within 30 days of treatment. ED visits occurred between 1/2019-12/2021, including when the REES unit was open (3/2020-6/2021). Preventable ED visits were defined as having one of ten primary diagnoses, which have been identified by OP-35. Of these, COVID-related diagnoses included fever, pneumonia, sepsis, neutropenia and diarrhea. Interrupted time series analyses were utilized to investigate the association between the REES unit opening and preventable ED visits. Results: 3,107 patients on chemotherapy were assessed in the ED from 1/2019-12/2021. Per week, there were 19.9 ED visits, 39.7% of which were for OP-35 diagnoses. When the REES unit opened, there was a 30% (95% CI -53% to -7%) reduction in preventable ED visits, corresponding to 2.62 (95% CI -4.61 to -0.63) fewer preventable ED evaluations per week. The primary driver of this reduction were presentations for COVID-related diagnoses, as there were 38% (95% CI -76% to -0.3%) fewer preventable ED visits weekly. During this period, there were approximately 6.9 patient visits per week to the REES unit. Conclusions: The introduction of an oncology urgent care clinic focusing on patients with symptoms of COVID-19 was associated with a reduction in potentially preventable ED visits. This analysis demonstrates the potential value of oncology urgent care clinics in reducing ED overcrowding and decreasing OP-35 related evaluations, which has patient experience, infection exposure and financial implications.[Table: see text]

Background Non-urgent use of the emergency department (ED) is costly for patients. It can lead to increased healthcare spending and ED overcrowding and negatively affect primary care physician (PCP)-patient relationships. We aim to evaluate the association between perceived medical urgency, PCP coverage (whether a patient has a PCP), and patient descriptive characteristics with utilization of the ED for non-urgent clinical care. Methods Adult ED patients were stratified to preventable and non-preventable ED visits according to their emergency severity index (ESI) at the UC Irvine ED. A REDCap questionnaire was used to assess descriptive information, self-perceived medical urgency, and PCP Coverage. Chi-Square tests at a 5% significance level were performed to examine differences between race, native language, self-perceived medical urgency, and PCP coverage between preventable and non-preventable ED visits. Results Study participants included 348 adult patients (52% female), of which 160 (46%) were preventable visits (ESI 4-5). There were more preventable visits among Black patients compared to non-Black patients (69.6% vs 30.4%, p=0.028) and the preventable group had less native English speakers than the non-preventable group (38.8% vs 61.2%, p=0.035). Compared to patients in the non-preventable ED visit group, patients in the preventable group are more likely to agree that they could have been seen and treated effectively by a PCP (p=0.003). Fewer patients in the preventable group have a PCP that they can see regularly and make an appointment with compared to the non-preventable group (40.3% vs 59.7%, p=0.004). Conclusion Our results indicate that Black patients and non-native English speakers were overrepresented in preventable ED visits compared to their counterparts, suggesting these patients may be more vulnerable to the plethora of negative consequences associated with utilizing the ED for non-emergent medical services. In addition, our study also revealed that patients in the preventable ED visit group were less likely to have a PCP, even though they were more likely to agree that a PCP could manage their symptoms. Future interventions are needed to address this lack of PCP coverage among preventable ED patients to reduce patient financial burden, ED overcrowding, and overall healthcare spending.

High rates of potentially preventable hospitalizations and emergency department (ED) visits indicate limited primary care access. Rural Health Clinics (RHCs) are intended to increase access to primary care. The goal of this study was to evaluate the role of RHCs and their impact on potentially preventable hospitalizations and ED visits among Medicare beneficiaries based on actual individual-level utilization patterns. With Medicare Part A and Part B claims data from 2007 to 2010, we constructed a series of individual-level negative binomial regression models to examine the relationship between RHC use and the number of potentially preventable hospitalizations and ED visits. RHC use was associated with a 27% increase in potentially preventable hospitalizations and a 24% increase in potentially preventable ED visits among older Medicare enrollees. Among younger, disabled Medicare beneficiaries, RHC use was associated with a 14% increase in potentially preventable hospitalizations and an 18% increase in potentially preventable ED visits. Potentially preventable hospitalizations and ED visits were more common among beneficiaries who were black or who had more chronic conditions. The results of our study highlight that the Medicare population using RHCs is at especially high risk for potentially preventable hospitalizations and ED visits. The mechanisms behind this are not well understood and should receive continued attention from policy makers and researchers.

241 Background: Reducing ED visits in patients with cancer is cost saving and is particularly relevant during the COVID pandemic. We aim to identify patterns of ED visits among various cancer patients and reduce preventable ED visits and hospital admissions. Methods: We analyzed the number of ED visits and hospital admissions that occurred in patients with breast, lung, and Gastrointestinal (GI) cancers between July12019 and October31 2020 including demographics, stage, treatment type preceding the month of ED visit, reason, time of the day, day of the week the visit occurred. Results: 308 patients had 519 ED visits, 111 breast cancer patients had 184, 102 lung cancer patients had 186 and 95 GI cancer patients had 149 ED visits. 38% had > 1 visit. 51%, (37% breast, 60% Lung and 58 % GI cancer) had stage 4 disease at the time of visit. There were no visits in the month of May 2020. 275 (53%) visits required hospital admissions, 60% of ED visits in lung cancer, 54% in GI and 46 % in breast cancer patients required hospitalization. Most common reason for ED visits in breast cancer patients was fall/injury (20%), with median age of 71 years, none were cancer/ chemotherapy induced. Among lung and GI cancer patients respiratory (24%) and GI related (24%) symptoms were the most common reasons respectively, majority were cancer/chemotherapy related. Most common symptoms requiring hospital admissions were respiratory 21%, GI 18%, cardiac 12%. 11% and 9% of ED visits were due to fall/injury and cancer related pain, of these 3.6% and 9% resulted in hospital admissions respectively. Lung and GI cancer patients were more likely to be referred to the ED from the oncologist office (23%) than breast cancer patients (11%). Conclusions: Reasons for ED visits vary by tumor types and some may be preventable. Fall/injury in breast cancer patients and cancer related pain in lung and GI cancer patients were frequent reasons for preventable ED visits. In lung and GI cancer patients, cancer/chemotherapy related respiratory, GI symptoms are felt to be less avoidable since they may be related to disease progression or presenting symptoms. We have initiated several strategies such as ‘’systematic physical therapy assessment’’ of our breast cancer patients over age 70 to reduce ED visits due to fall/injury. We are developing strategies to involve palliative care early to reduce the number of ED visits related to cancer related pain We now have “call us first campaign” to assess and intervene before going to ED since most visits occurred during working hours.[Table: see text]

BackgroundTaiwan implemented global hospital budgeting with a floating-point value, which created a prisoner's dilemma. As a result, hospitals increased service volume, which caused the floating-point value to drop to less than one New Taiwan Dollar (NTD). The recent increase in the number of hospital beds and the call to enhance the floating-point value to one NTD raise concerns about the potential for increased financial burden without adding value to patient care if hospitals expand their bed capacity for volume-based competition. The present study aimed to examine the relationship between the supply of hospital beds and hospitalizations following an emergency department (ED) visit (called ED hospitalizations) by using diabetes-related ambulatory care sensitive conditions (ACSCs) that are preventable and discretionary as an example.MethodsThe study was a pooled cross-sectional design analyzing 2011–2015 population-based claims data in Taiwan. The dependent variable was a dummy variable representing an ED hospitalization, with a treat-and-leave ED visit as the reference group. The key independent variable is the number of hospital beds per 1,000 populations. Multivariate logistic regression models with and without a clustering function were used for the analyses.ResultsApproximately 59.26% of diabetes-related ACSCs ED visits resulted in ED hospitalizations. The relationship between the supply of hospital beds and ED hospitalizations was statistically significant (OR = 1.12; 95% CI: 1.09–1.14; P < 0.001) in the model without clustering but was statistically insignificant in the model with clustering (OR = 1.03; 95% CI: 0.94–1.12; P > 0.05). Several social risk factors were positively associated with the likelihood of ED hospitalizations, such as low income and the percentage of the population without a high school diploma. In contrast, other factors, such as female patients and the Charlson comorbidity index, were negatively associated with the likelihood of ED hospitalizations.ConclusionUnder hospital global budgeting with a floating-point value mechanism, increases in hospital beds likely motivate hospitals to admit ED patients with preventable and discretionary conditions. Our study emphasizes the urgent need to add value-based incentive mechanisms to the current global budget payment. The value-based incentive mechanisms may encourage providers to focus on quality of patient care by addressing social risk factors rather than engage in volume-based competition, which would improve population health while reducing preventable ED visits and hospitalizations.

Introduction: Hospitals are a major source of care for underserved populations in the United States. However, little is known about how hospital-based health information technology (HIT) can improve the efficiency of care and reduce disparities. Objective: We examined the variation of preventable emergency department (ED) visits and associated racial disparities by hospital adoption of HIT patient engagement (HIT-PE) functionalities. Methods: This was an observational study of 6,543,514 non-Hispanic Black (Black) and non-Hispanic White (White) adult patients using 2019 datasets of seven states (Arizona, Florida, Kentucky, Maryland, North Carolina, Vermont, Wisconsin) from the State Emergency Department Databases, American Hospital Association Annual Survey & Information Technology Supplement, and Area Health Resources File. Results: High HIT-PE adoption was associated with lower rates of preventable ED (odds ratio [OR] = 0.992, p < 0.001). Specific HIT-PE functions such as importing medical records from other organizations into the patient portal (OR = 0.977, p < 0.001), electronically sending medical information to a third party (OR = 0.970, p < 0.001), and scheduling appointments online (OR = 0.987, p < 0.001) were also associated with reduced preventable ED rates. Black patients had higher rates of preventable ED compared with Whites (OR = 1.386, p < 0.001); however, the interaction of Black patients and high HIT-PE adoption was associated with lower rates of preventable ED (OR = 0.977, p < 0.001). Our results also showed that higher HIT-PE adoption was associated with a reduction in preventable ED visits among Black patients with comorbidities and Black patients living in low-income areas. Conclusions: The results of our study suggest that there is potential to reduce preventable ED rates and racial disparities through hospital-based HIT-PE functionalities.

Systemic lupus erythematosus (SLE) patients are prone to frequent emergency department (ED) visits. This study explores the epidemiology and outcomes of ED visits by patients with SLE utilizing the Nationwide Emergency Department Sample (NEDS). Using NEDS (2019), SLE ED visits identified using ICD-10 codes (M32. xx) were compared with non-SLE ED visits in terms of demographic and clinical features and primary diagnoses associated with the ED visits. Factors associated with inpatient admission were analyzed using logistic regression. Variations in ED visits by age and race were assessed. We identified 414,139 (0.35%) ED visits for adults ≥ 18years with SLE. ED visits with SLE comprised more women, Black patients, ages 31-50years, Medicare as the primary payer, and had higher comorbidity burden. A greater proportion of Black and Hispanic SLE patients who visited the ED were in the youngest age category of 18-30years (around 20%) compared to White patients (less than 10%). Non-White patients had higher Medicaid utilization (27%-32% vs 19% in White patients). Comorbidity patterns varied based on race, with more White patients having higher rates of hyperlipidemia and ischemic heart disease (IHD) and more Black patients having chronic kidney disease (CKD), hypertension, and heart failure. Categorizing by race, SLE/connective tissue disease (CTD) and infection were the most prevalent primary ED diagnosis in non-White and White patients, respectively. Age ≥ 65years, male sex, and comorbidities were linked to a higher risk of admission. Black race (OR 0.86, p = .01) and lowest income quartile (OR 0.78, p = .003) had lower odds of inpatient admission. Infection and SLE/CTD were among the top diagnoses associated with ED visits and inpatient admission. Despite comprising a significant proportion of SLE ED visits, Black patients had lower odds of admission. While the higher prevalence of older age groups, hyperlipidemia, and IHD among White patients may partly explain the disparate results, and further study is needed to understand the role of other factors including reliance on the ED for routine care compared among Black patients, differences in insurance coverage, and potential socioeconomic biases among healthcare providers.

This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence. A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence. There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC. There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.

Measurement of the quality of US health care increasingly emphasizes clinical outcomes over clinical processes. Nursing Home Compare Star Ratings are provided by Medicare to help select better nursing home care. The authors determined the rates and types of 2 important clinical outcomes–potentially preventable hospital admissions and potentially preventable emergency department (ED) visits–for a subset of 439,011 long-term nursing homes residents residing in 12,883 nursing homes throughout the United States over a 2-year period (2010–2011) and compared them with the Star Rating system. This study found that (1) the likelihood of potentially preventable events increases with increasing burden of chronic illness, (2) the principle reasons for hospital admissions and ED visits (eg, septicemia, pneumonia, confusion, gastroenteritis) are not part of existing nursing home quality measures, (3) the rate of potentially preventable admissions and ED visits for nursing homes residents varies greatly both across and within states, with 5 states having in excess of 20% more than the national average for both, and (4) the Nursing Home Compare Stars measure has limited correlation with rates of these potentially preventable events. Nursing Home Compare Star rankings could benefit by incorporating outcomes measures such as preventable hospitalizations and ED visits, and by comparing nursing home performance on results drawn from across states rather than within them. Such reform could better help users find nursing homes of higher quality and stimulate homes to improve quality in ways that benefit residents.

There are few proven strategies to reduce the frequency of potentially preventable hospitalizations and Emergency Department (ED) visits. To facilitate strategy development, we documented these events among complex patients and the factors that contribute to them in a large care-improvement initiative. Observational study with retrospective audits and selective interviews by the patients' care managers among 12 diverse medical groups in California, Minnesota, Pennsylvania, and Washington that participated in an initiative to implement collaborative care for patients with both depression and either uncontrolled diabetes, uncontrolled hypertension, or both. We reviewed information about 373 adult patients with the required conditions who belonged to these medical groups and had experienced 389 hospitalizations or ED visits during the 12-month study period from March 30, 2014, through March 29, 2015. The main outcome measures were potentially preventable hospitalizations or ED visit events. Of the studied events, 28% were considered to be potentially preventable (39% of ED visits and 14% of hospitalizations) and 4.6% of patients had 40% of events. Only type of insurance coverage; patient lack of resources, caretakers, or understanding of care; and inability to access clinic care were more frequent in those with potentially preventable events. Neither disease control nor ambulatory care-sensitive conditions were associated with potentially preventable events. Among these complex patients, patient characteristics, disease control, and the presence of ambulatory care-sensitive conditions were not associated with likelihood of ED visits or hospital admissions, including those considered to be potentially preventable. The current focus on using ambulatory care-sensitive conditions as a proxy for potentially preventable events needs further evaluation.

Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time. Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade. Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends. Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017. US adults, an annual average of 241.3 million individuals. Preventable ED visits and hospitalizations. Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents. Observational study; unable to infer causality. Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.

1511 Background: Acute care use is one of the largest drivers of cancer care costs. OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy is a CMS quality measure that will affect reimbursement based on unplanned inpatient admissions (IP) and emergency department (ED) visits. Targeted measures can reduce preventable acute care use but identifying which patients might benefit remains challenging. Prior predictive models have made use of a limited subset of the data available in the Electronic Health Record (EHR). We hypothesized dense, structured EHR data could be used to train machine learning algorithms to predict risk of preventable ED and IP visits. Methods: Patients treated at Stanford Health Care and affiliated community care sites between 2013 and 2015 who met inclusion criteria for OP-35 were selected from our EHR. Preventable ED or IP visits were identified using OP-35 criteria. Demographic, diagnosis, procedure, medication, laboratory, vital sign, and healthcare utilization data generated prior to chemotherapy treatment were obtained. A random split of 80% of the cohort was used to train a logistic regression with least absolute shrinkage and selection operator regularization (LASSO) model to predict risk for acute care events within the first 180 days of chemotherapy. The remaining 20% were used to measure model performance by the Area Under the Receiver Operator Curve (AUROC). Results: 8,439 patients were included, of whom 35% had one or more preventable event within 180 days of starting chemotherapy. Our LASSO model classified patients at risk for preventable ED or IP visits with an AUROC of 0.783 (95% CI: 0.761-0.806). Model performance was better for identifying risk for IP visits than ED visits. LASSO selected 125 of 760 possible features to use when classifying patients. These included prior acute care visits, cancer stage, race, laboratory values, and a diagnosis of depression. Key features for the model are shown in the table. Conclusions: Machine learning models trained on a large number of routinely collected clinical variables can identify patients at risk for acute care events with promising accuracy. These models have the potential to improve cancer care outcomes, patient experience, and costs by allowing for targeted preventative interventions. Future work will include prospective and external validation in other healthcare systems.[Table: see text]

We assessed whether proactive care management for artificial intelligence (AI)-identified at-risk patients reduced preventable emergency department (ED) visits and hospital admissions (HAs). Stepped-wedge cluster randomized design. Adults receiving primary care at 48 UCLA Health clinics and determined to be at risk based on a homegrown AI model were included. We employed a stepped-wedge cluster randomized design, assigning groups of clinics (pods) to 1 of 4 single-cohort waves during which the proactive care intervention was implemented. The primary end points were potentially preventable HAs and ED visits; secondary end points were all HAs and ED visits. Within each wave, we used an interrupted time series and segmented regression analysis to compare utilization trends. In the pooled analysis of high-risk and highest-risk patients (n = 3007), potentially preventable HAs showed a statistically significant level drop (-27% [95% CI, -44% to -6%]), without any corresponding change in trends. Potentially preventable ED visits did not show a substantial level drop in response to the intervention, although a nonsignificant differential change in trend was observed, with visit rates decelerating 7% faster in the intervention cohorts (95% CI, -13% to 0%). Nonsignificant drops were observed for all HAs (-19% [95% CI, -35% to 1%]; P = .06) and ED visits (-15% [95% CI, -28% to 1%]; P = .06). A care management intervention targeting AI-identified at-risk patients was followed by a onetime, significant, sizable reduction in preventable HA rates. Further exploration is needed to assess the potential of integrating AI and care management in preventing acute hospital encounters.

The aim of this study was to explore the efficacy of current bariatric perioperative measures at reducing emergency department (ED) visits following bariatric surgery in the state of Michigan. Many ED visits following bariatric surgery do not result in readmission and may be preventable. Little research exists evaluating the efficacy of perioperative measures aimed at reducing ED visits in this population. Therefore, understanding the driving factors behind these preventable ED visits may be a fruitful approach to prevention. Furthermore, evaluating the efficacy of current perioperative measures may shed light on how to achieve meaningful reductions in ED visits. We studied 48,035 eligible bariatric surgery patients across 37 Michigan Bariatric Surgical Collaborative (MBSC) sites between January 2012 and October 2015. Hospitals were ranked according to their risk- and reliability-adjusted ED visit rates. For hospitals in each ED visit rate tercile, several patient, surgery, and hospital summary characteristics were compared. We then studied whether a hospital's compliance with specific perioperative measures was significantly associated with reduced ED visit rates. Only 3 of the 30 surgery, hospital, and patient summary characteristics studied were significant predictors of a hospital's ED visit rate: rate of sleeve gastrectomies, rate of readmissions, and rate of venous thromboembolism complications (P = 0.04, P = 0.0065, and P = 0.0047, respectively). Also, a hospital's compliance with the perioperative measures evaluated was not a significant predictor of ED visit rates (P = 0.12). Current practices aimed at reducing ED visits appear to be ineffective. Due to heterogeneity in patient populations and local infrastructure, a more tailored approach to ED visit reduction may be more successful.

IntroductionPreventable hospitalizations for angina have been decreasing since the late 1980s — most likely because of changes in guidance, physician coding practices, and reimbursement. We asked whether this national decline has continued and whether preventable emergency department visits for angina show a similar decline.MethodsWe used National Hospital Discharge Survey data from 1995 through 2010 and National Hospital Ambulatory Medical Care Survey data from 1995 through 2009 to study preventable hospitalizations and emergency department visits, respectively. We calculated both crude and standardized rates for these visits according to technical specifications published by the Agency for Healthcare Research and Quality, which uses population estimates from the US Census Bureau as the denominator for the rates.ResultsCrude hospitalization rates for angina declined from 1995–1998 to 2007–2010 for men and women in all 3 age groups (18–44, 45–64, and ≥65) and age- and sex-standardized rates declined in a linear fashion (P = .02). Crude rates for preventable emergency department visits for angina declined for men and women aged 65 or older from 1995–1998 to 2007–2009. Age- and sex-standardized rates for these visits showed a linear decline (P = .05).ConclusionWe extend previous research by showing that preventable hospitalization rates for angina have continued to decline beyond the time studied previously. We also show that emergency department visits for the same condition have also declined during the past 15 years. Although these declines are probably due to changes in diagnostic practices in the hospitals and emergency departments, more studies are needed to fully understand the reasons behind this phenomenon.