Avoidable Emergency Department Visits Research Articles

The feasibility, acceptability and appropriateness of screening for frailty in Australians aged 75 years and over attending Australian general practice

Background Globally, frailty is associated with a high prevalence of avoidable hospital admissions and emergency department visits, with substantial associated healthcare and personal costs. International guidelines recommend incorporation of frailty identification and care planning into routine primary care workflow to support patients who may be identified as pre-frail/frail. Our study aimed to: (1) determine the feasibility, acceptability, appropriateness and determinants of implementing a validated FRAIL Scale screening Tool into general practices in two disparate Australian regions (Sydney North and Brisbane South); and (2) map the resources and referral options required to support frailty management and potential reversal. Methods Using the FRAIL Scale Tool, practices screened eligible patients (aged ≥75 years) for risk of frailty and referred to associated management options. The percentage of patients identified as frail/pre-frail, and management options and referrals made by practice staff for those identified as frail/pre-frail were recorded. Semi-structured qualitative interviews were conducted with practice staff to understand the feasibility, acceptability, appropriateness and determinants of implementing the Tool. Results The Tool was implemented by 19 general practices in two Primary Health Networks and 1071 consenting patients were assessed. Overall, 80% of patients (n = 860) met the criterion for frailty: 33% of patients (n = 352) were frail, and 47% were pre-frail (n = 508). They were predominantly then referred for exercise prescription, medication reviews and geriatric assessment. The Tool was acceptable to staff and patients and compatible with practice workflows. Conclusions This study demonstrates that frailty is identified frequently in Australians aged ≥75 years who visit their general practice. It’s identification, linked with management support to reverse or reduce frailty risk, can be readily incorporated into the Medicare-funded annual 75+ Health Assessment.

Healthcare Utilization of Oral and Oropharyngeal Cancer Patients in Emergency Department and Outpatient Settings: An 8-year Population-Based Study.

This study aimed to determine trends in the healthcare utilization by Oral Cavity and Oropharyngeal cancer patients across emergency department (ED) and outpatient settings in Alberta and examine the predictors of ED visits. This is a retrospective, population-based, cohort study using administrative data collected by all healthcare facilities between 2010 and 2019 in Alberta, Canada. Trend of visits to different facilities, patients' primary diagnosis, and predictors of ED visits were analyzed. In total, 34% of patients had at least one cancer-related ED visit. With a rise of 31% in cancer incidence, there was a notable upswing in visits to outpatient clinics and community offices, while ED visits decreased. Cancer stage, rural residence, high material deprivation score, and treatments were found as predictors of ED visits. Improved symptom management and better care access for disadvantaged and rural oral cancer patients may decrease avoidable ED visits.

563 Team Science to Assess Effectiveness and Impact in Public Healthcare Delivery System Contracting

OBJECTIVES/GOALS: Healthcare organizations and payers are moving from accountability to effectiveness frameworks. Static vendor contracts for full-scale implementation limit organizations' ability to evaluate impact before scale-up, or to iteratively improve. Our team science innovation employs science and learning methods as systems engage vendors. METHODS/STUDY POPULATION: Our team science innovation is a method to assess and model impact of interventions at scale in healthcare delivery systems. We are integrating expertise in learning processes of an academic medical center (UCLA CTSI) with the organizational knowledge and methodological expertise of the nation’s largest Medicaid managed care plan (LA Care Health Plan), which has over 2 million members. The LA Care Advanced Analytics Lab has unique capability in machine learning, while enables deep learning of variation. Our innovative product is a template to quickly mobilize evaluation and learning for a diverse population in a varied and distributed delivery system. The template design enables rapid learning for the full-scale policy implementation often imposed by government, and in the short timeframes involved. RESULTS/ANTICIPATED RESULTS: LA Care and the UCLA CTSI partnered to provide subject matter expertise and design effective pilots for interventions such as transitional care services, complex care management, and physician home visit strategies, accounting for confounding factors affecting the intervention and outcome. So far, collaborative modeling and design has produced a successful pilot of a physician home visit program intended to reduce avoidable emergency department visits. This pilot quickly revealed several major changes that would need to be incorporated for the contracted vendor to produce results if operated at scale, further informed by machine learning, in sufficient time to inform the contracting process. There are multiple evolving applications, including housing/homelessness. DISCUSSION/SIGNIFICANCE: Integrating the large data and analytics of a large healthcare organization with learning methods from the CTSI -- including learning from variation and designs for studying impact during scale-up -- fosters academic-community team science that could significantly improve the value of our largest delivery systems, public and commercial.

Avoidable emergency department visits among palliative care cancer patients: novel insights from Saudi Arabia and the Middle East

BackgroundSeveral studies emerging from developed countries have highlighted a significant number of potentially avoidable emergency department (ED) visits by cancer patients during the end-of-life period. However, there is a paucity of information from developing nations regarding palliative care practices and the utilization of the ED by palliative care patients. Herein, we aim to characterize ED admissions among patients receiving palliative care at our tertiary center in Saudi Arabia.MethodsThis is a retrospective, cross-sectional study evaluating ED visits amongst adult patients with advanced cancer who were receiving treatment under the palliative care department. This study took place over a period of 12 months from July 2021 through to July 2022. Three palliative care specialist physicians independently and blindly reviewed each patient’s ED visits and determined whether the visit was avoidable or unavoidable.ResultsA total of 243 patients were included in the final analysis, of which 189 (78.1%) patients had unavoidable visits and 53 (21.9%) patient visits were classified as avoidable. A significantly higher proportion of breast cancer patients presented with unavoidable admissions (14.3% vs. 3.8%, P = 0.037) compared to other cancer types. The incidence of dyspnea (23.8% vs. 5.7%, P < 0.001) and fevers/chills (23.3% vs. 5.7%, P = 0.005) was significantly higher in patients with unavoidable visits. Patients with avoidable visits had a significantly greater proportion of visits for dehydration (13.2% vs. 2.1%, P = 0.002). Notably, although hospital stay was significantly longer in the unavoidable group (P = 0.045), mortality for palliative care patients—regardless of whether their ED visit was avoidable or unavoidable—was not statistically different (P=-0.069).ConclusionTo our knowledge, this is the largest and most comprehensive study from Saudi Arabia and the Middle East providing insights into the utilization of palliative care services in the region and the propensity of advanced cancer patients towards visiting the ED. Future studies ought to explore interventions to reduce the frequency of avoidable ED visits.

Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization.

Sickle cell disease (SCD) has a history of health inequity, as patients with SCD are primarily Black and often marginalized from the health care system. Although recent health care and treatment advancements have prolonged life expectancy, it may be insufficient to support the complex needs of the growing population of older adults with SCD. This retrospective study used a cohort (N = 812) of Medicare Advantage beneficiaries 45 years and older (ages: 45-54, 55-64, 65-74, 75-89) with SCD to identify associations of SCD-related complications and comorbidities with emergency department (ED) visits, potentially avoidable ED visits, all-cause hospitalization, and potentially avoidable hospitalizations, 2018-2020. The 75-89 age group had lower odds of an ED visit (OR 0.56; 95% CI 0.32-1.00), 65-74 age group had lower odds of an ED visit (OR 0.49; 95% CI 0.31-0.78) and hospitalization (OR 0.50; 95% CI 0.31-0.79), compared with the 45-54 age group. Acute chest syndrome was associated with increased odds of an ED visit (OR 2.02; 95% CI 1.10-3.71), avoidable ED visit (OR 1.87; 95% CI 1.14-3.06), and hospitalization (OR 3.61; 95% CI 2.06-6.31). Pain was associated with increased odds of an ED visit (OR 2.64; 95% CI 1.85-3.76), an avoidable ED visit (OR 3.08; 95% CI 1.90-4.98), hospitalization (OR 1.51; 95% CI 1.02-2.24), and avoidable hospitalization (OR 6.42; 95% CI 1.74-23.74). Older adults with SCD have been living with SCD for decades, often while managing pain crises and complications associated increased incidence of an ED visit and hospitalization. The characteristics and needs of this population must continue to be examined to increase preventative care and reduce costly emergent health care resource utilization.

Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers

BackgroundLimited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs.MethodsThis national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0–17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates.ResultsA total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients.ConclusionsIn this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.

Incidence and cost of potentially avoidable emergency department visits for urolithiasis.

Urolithiasis represents a leading cause of emergency department (ED) presentation nationally, affecting approximately 10% of Americans. However, most patients require neither hospital admission nor surgical intervention. This study investigates patient and facility factors associated with potentially avoidable ED visits and their economic consequences. Retrospective analysis. Patients presenting to the ED for index urolithiasis events were selected using Florida and New York all-payer data from the 2016 Healthcare Cost and Utilization Project state databases. Avoidable visits were defined as subsequent ED encounters following initial ED presentation that did not result in intervention, admission, or referral to an acute care facility. Utilizing multivariable logistic and linear regression, researchers discerned patient and facility factors predictive of avoidable ED presentations and associated costs. Of the 167,102 ED encounters for urolithiasis, 7.9% were potentially avoidable, totaling $94,702,972 in potential yearly cost savings. Mean encounter-level costs were higher for unavoidable vs avoidable visits ($5885 vs $2098). In contrast, mean episode-based costs were similar for avoidable and unavoidable episodes ($7200 vs $7284). Receiving care in small metropolitan (vs large metropolitan) communities was associated with potentially avoidable visits, whereas increased comorbidities and Hispanic ethnicity were protective against avoidable visits. The incidence of ED use for subsequent urolithiasis care reveals opportunity for enhanced outpatient availability to reduce hospital-based costs. Several nonclinical factors are associated with potentially avoidable ED visits for urolithiasis, which, if appropriately targeted, may represent an opportunity to reduce health care spending without compromising the quality of care delivery.

Patterns of Morbidity Across the Lifespan

Background: Classification systems to segment such patients into subgroups for purposes of care management and population analytics should balance administrative simplicity with clinical meaning and measurement precision. Objective: To describe and empirically apply a new clinically relevant population segmentation framework applicable to all payers and all ages across the lifespan. Research Design and Subjects: Cross-sectional analyses using insurance claims database for 3.31 Million commercially insured and 1.05 Million Medicaid enrollees under 65 years old; and 5.27 Million Medicare fee-for-service beneficiaries aged 65 and older. Measures: The “Patient Need Groups” (PNGs) framework, we developed, classifies each person within the entire 0–100+ aged population into one of 11 mutually exclusive need-based categories. For each PNG segment, we documented a range of clinical and resource endpoints, including health care resource use, avoidable emergency department visits, hospitalizations, behavioral health conditions, and social need factors. Results: The PNG categories included: (1) nonuser, (2) low-need child, (3) low-need adult, (4) low-complexity multimorbidity, (5) medium-complexity multimorbidity, (6) low-complexity pregnancy, (7) high-complexity pregnancy, (8) dominant psychiatric/behavioral condition, (9) dominant major chronic condition, (10) high-complexity multimorbidity, and (11) frailty. Each PNG evidenced a characteristic age-related trajectory across the full lifespan. In addition to offering clinically cogent groupings, large percentages (29%–62%) of patients in two pregnancy and high-complexity multimorbidity and frailty PNGs were in a high-risk subgroup (upper 10%) of potential future health care utilization. Conclusions: The PNG population segmentation approach represents a comprehensive measurement framework that captures and categorizes available electronic health care data to characterize individuals of all ages based on their needs.

Factors related to the frequent use of emergency department services in Korea

BackgroundFrequent Emergency Department (ED) visitors are identified by the policymakers to reduce avoidable ED visits and lessen the financial and operational burden. This study aimed to identify the factors related to the frequent use of ED services.MethodsThis nationwide, cross-sectional observational study was conducted using information obtained from the 2019 National Emergency Department Information System (NEDIS) database. Frequent ED users were defined as patients with four or more ED visits a year. We performed multiple logistic regression analyses to verify the relationship among sociodemographic characteristics, residential characteristics, clinical characteristics, and frequency of ED visits.ResultsAmong 4,063,640 selected patients, 137,608 patients visited the ED four or more times a year (total number of visits = 735,502 times), which accounted for 3.4% and 12.8% of the total number of ED users and ED visits, respectively. A high ED visit frequency was associated with male sex, age < 9 or ≥ 70 years, Medical Aid (based on the insurance type), lower number of medical institutions and beds compared with that of the national average, and conditions, such as cancer, diabetes, renal failure, and mental illness. A low ED-visit frequency was associated with residence in regions vulnerable to emergency medical care and regions with high income. The possibility of frequent ED visits was high for patients with level 5 severity (non-emergent) and those with an increased need for medical treatment, including older patients and patients with cancer or mental illness. The possibility of frequent ED visits was low for patients aged > 19 years with level 1 severity (resuscitation).ConclusionsHealth service accessibility factors, including low income and medical resource imbalance, were associated with frequent ED visits. Future large-scale prospective cohort studies are warranted to establish an efficient emergency medical system.

Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries.

Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization. A cluster randomized trial approach with a stepped wedge design was used to test the effect of the community paramedicine intervention. ED utilization for non-urgent care was measured by emergency medicine ED visits and avoidable ED visits. The community paramedicine intervention reduced ED utilization among a sample of 102 medically complex Medicaid beneficiaries with a history of high ED utilization. In the unadjusted models, emergency medical ED visits decreased by 13.9% (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.76-0.98) or 6.1 visits saved for every 100 people. Avoidable emergency department visits decreased by 38.9% (IRR, 0.61; 95% CI, 0.44-0.84) or 2.3 visits saved for every 100 people. Our results suggest community paramedicine is a promising model to achieve a reduction in ED utilization among medically complex patients by managing complex health conditions in a home-based setting.

Identifying facilitators and barriers to integrated and equitable care for community-dwelling older adults with high emergency department use from historically marginalized groups

BackgroundHigh rates of emergency department (ED) use by older adults persist despite attempts to improve accessibility of appropriate and comprehensive care. Understanding the drivers of ED visits from the perspective of older adults from historically marginalized groups could help reduce ED use by patients with needs that are preventable or could have been treated in a more appropriate setting. This interpretivist, feminist study aims to explore the unmet care needs of older adults (age 65 +) with high ED use and belonging to historically marginalized groups to better understand how social and structural inequities reinforced by neoliberalism; federal and provincial governance structures and policy frameworks; and regional processes and local institutional practices, shape the experiences of these older adults, particularly those at risk of poor health outcomes based on the social determinants of health (SDH).Methods/designThis mixed methods study will employ an integrated knowledge translation (iKT) approach, starting with a quantitative phase followed by a qualitative phase. Older adults self-identifying as belonging to a historically marginalized group, having visited an ED three or more times in the past 12 months, and living in a private dwelling, will be recruited using flyers posted at two emergency care sites and by an on-site research assistant. Data obtained through surveys, short answer questions, and chart review will be used to compile case profiles of patients from historically marginalized groups with potentially avoidable ED visits. Descriptive and inferential statistical analyses and inductive thematic analysis will be conducted. Findings will be interpreted using the Intersectionality-Based Policy Analysis Framework to identify the interconnections between unmet care needs, potentially avoidable ED admissions, structural inequalities, and the SDH. Semi-structured interviews will be conducted with a subset of older adults at risk of poor health outcomes based on SDH, family care partners, and health care professionals to validate preliminary findings and collect additional data on perceived facilitators and barriers to integrated and accessible care.DiscussionExploring the linkages between potentially avoidable ED visits by older adults from marginalized groups and how their care experiences have been shaped by inequities in the systems, policies, and institutions that structure health and social care provision will enable researchers to offer recommendations for equity-focused policy and clinical practice reforms to improve patient outcomes and system integration.

School-Based Telemedicine and Reduced Avoidable Emergency Care Among Rural Pediatric Patients.

Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.

Virtual Fracture Care in Long-Term Care Homes Avoiding Emergency Department Visits.

Long-term care residents with suspected fractures as a result of a fall typically transfer to the emergency department (ED) for diagnostic imaging and care. During the COVID-19 pandemic, transfer to the hospital increased the risk of COVID-19 exposure and resulted in extended isolation days for the resident. A fracture care pathway was developed and implemented to provide rapid diagnostic imaging results and stabilization in the care home, reducing transportation and exposure risk to COVID-19. Eligible residents with a stable fracture would receive a referral to a designated fracture clinic for consultation; fracture care is provided in the care home by long-term care staff. Evaluation of the pathway was completed and demonstrated that 100% of residents did not transfer to the ED and 47% of the residents did not transfer to a fracture clinic for additional care.

The role of social connections and support in the use of emergency care among older adults

ObjectivesLimited and inconsistent findings have been reported on the link between social connections and support and emergency department (ED) visits in older populations. Moreover, the adequacy of informal care for older adults has rarely been considered. This study explored the associations of social connections, social support, and informal care with ED visits in younger-old (<78 years) and oldest-old (≥78 years) adults. MethodsThis is a prospective cohort study based on community-living adults ≥60 years old participating in the Swedish National Study on Aging and Care in Kungsholmen (N=3066 at wave 1, 2001-2004; N=1885 at wave 3, 2007-2010; N=1208 at wave 5, 2013-2016). Standardised indexes were developed to measure social connections, social support, and informal care. The outcome variable was hospital-based ED visits within 4 years of the SNAC-K interview. Associations between exposure variables and ED visits were assessed through negative binomial regressions using generalised estimating equations. ResultsMedium (IRR 0.77; 95% CI 0.59–0.99) and high (IRR 0.77; 95% CI 0.56–0.99) levels of social support were negatively associated with ED visits compared to low levels of social support, but only in oldest-old adults. No statistically significant associations were observed between social connections and ED visits. Higher ED visit rates were seen in oldest-old adults with unmet informal care needs, even if the differences did not reach statistical significance. ConclusionsED visits were associated with social support levels among adults aged ≥78 years. Public health interventions to mitigate situations of poor social support may improve health outcomes and reduce avoidable ED visits in oldest-old adults.

Cross-sectional analysis of avoidable emergency department visits before and during the COVID-19 pandemic

BackgroundCOVID-19 had a significant impact on Emergency Departments (ED) with early data suggesting an initial decline in avoidable ED visits. However, the sustained impact over time is unclear. In this study, we analyzed ED discharges over a two-year time period after the COVID-19 pandemic began and compared it with a control time period pre-pandemic to evaluate the difference in ED visit categories, including total, avoidable, and unavoidable visits. MethodsThis was a retrospective, cross-sectional study assessing the distribution of visits with ED discharges from two hospitals within a health system over a three-year time period (1/1/2019–12/31/2021). Visits were categorized using the expanded NYU-EDA algorithm modified to include COVID-19-related visits. Categories included: Emergent - Not Preventable/Avoidable, Emergent – Preventable/Avoidable, Emergent - Primary Care Treatable, Non-Emergent, Mental Health, Alcohol, Substance Abuse, Injury, and COVID-19. Chi-square testing was conducted to investigate differences within the time period before COVID-19 (1/1/2019–12/31/2019) and both initial (1/1/2020–12/31/2020) and delayed (1/1/2021–12/31/2021) COVID-19 time frames and ED visit categories, as well as post hoc testing using Fisher's exact tests with Bonferroni correction. ANOVA with post hoc Bonferroni testing was used to determine differences based on daily census for each ED visit category. ResultsA total of 228,010 ED discharges (Hospital #1 = 126,858; Hospital #2 = 101,152) met our inclusion criteria over the three-year period. There was a significant difference in the distribution of NYU-EDA categories between the two time periods (pre-COVID-19 versus during COVID-19) for the combined hospitals (p < 0.001), Hospital #1 (p < 0.001), and Hospital #2 (p < 0.001). When examining daily ED discharges, there was a decline in all categories from 2019 to 2020 except for “Emergent - Not Preventable/Avoidable” which remained stable and “Substance Abuse” which increased. From 2020 to 2021, there were no differences in ED avoidable visits. However, there were increases in discharged visits related to “Injuries”, “Alcohol”, and “Mental health” and a decrease in “COVID-19”. ConclusionOur study identified a sustained decline in discharged avoidable ED visits during the two years following the beginning of the COVID-19 pandemic, which was partially offset by the increase in COVID-19 visits. This work can help inform ED and healthcare systems in resource allocation, hospital staffing, and financial planning during future COVID-19 resurgences and pandemics.

Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits.

Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.

Validation of a classification to identify emergency department visits suitable for subacute and virtual care models: a randomised single-blinded agreement study protocol

IntroductionRedirecting suitable patients from the emergency department (ED) to alternative subacute settings may assist in reducing ED overcrowding while delivering equivalent care. The Emergency Department Avoidance Classification (EDAC) was constructed...

Sickle Cell Disease May Qualify As an Ambulatory Care Sensitive Condition

Background Ambulatory care sensitive conditions (ACSCs) are conditions for which outpatient care can potentially prevent hospital visits.[i] Effective primary care is associated with lower hospitalization for ACSCs. These hospitalizations are also referred to as avoidable hospitalization.[ii] [iii] We hypothesized that sickle cell disease (SCD) qualifies as an ACSC. We partly tested that hypothesis in the context of an intense primarily ambulatory case management program that also includes urgent and inpatient management components. Methods As part of a SCD Adult Medical Home with multiple interventions, we assigned Community Health Workers (CHWs), called Patient Navigators (PNs), as case managers. A PN (one of two in 2018, and one of three in 2019, 2020, and 2021) was assigned to each of the program's top 50 highest utilizers, but also began periodically managing other patients ad hoc in 2019 (All adult patients, N=537 in 2017 to N=641 in 2021). Activities focused on education to improve self-care, assisting patients with medical appointments, and accessing services to combat adverse social determinants. PNs strove to reduce avoidable emergency department (ED) visits and hospitalizations. Interventions and visit activity included telephone, face-to-face clinic, face-to-face ED, face-to-face inpatient, or face-to-face community contact (restricted to telecommunication by COVID). Data and analyses from 2017 to 2021 included: 1) Spearman's correlation of inpatient discharges with outpatient visits; 2)Spearman's correlation of annual ED visits with annual outpatient visits; 3)calculation of ED Reliance Ratio (ERR, defined as ED visits/ED + ambulatory + inpatient visits), Spearman's correlation of ERR with annual costs, and ANOVA test for significance of ERR decreasing; 4) Spearman's correlation between costs and Inpatient discharge, and ANOVA test for significance of inpatient discharge decreasing. Results 1)Inpatient discharges started to drop with the increased outpatient visits in 2018 for all patients. Due to COVID-19, no significant inverse correlation was observed. However, an inverse Correlation between Inpatient Discharge vs. Outpatient Visit for top 50 utilizers was statistically significant (Spearman R=-0.17, p-value=0.02). 2) Spearman correlation did not show significant inverse correlation between ED_usage and outpatient visit for all patients due to suspected COVID effects. However, annual ED visit is almost inversely correlated with annual outpatient visits for the top 50 utilizers (Spearman R=-0.13, p =0. 05). 3)Total costs correlated with the ERR for 2017-2021, both for each year's top utilizers (Spearman R=0.40, p <0.0001), and for all patients (Spearman R=0.44, p<0.0001). ERR has been significantly decreased from 2017 to 2021 for all patients (ANOVA P=0.0089<0.05) and for top 50 utilizers (ANOVA P<0.0001). 4)In addition, the inpatient discharge positively correlated with total cost both for each year's top utilizers (Spearman R=0.70, p <0.0001), and for all patients (Spearman R=0.71, p<0.0001). The number of Inpatient hospitalizations decreased significantly. ANOVA shows p<0.0001 for both all patients and for top 50 utilizers. Conclusions Sickle cell disease appears to behave as an ACSC in our SCD sample. An intervention led to fewer ED visits and avoidable hospitalization. Annual total costs decreased accordingly during that same period. But some statistically expected utilization relationships were not observed. Future post-COVID utilization may confirm these findings, and studies of ACSC interventions with control groups in SCD patients may increase the validity of our before-after findings of intervention effects. 1. AHRQ Quality Indicators. Guide to prevention quality indicators: hospital admission for ambulatory care sensitive conditions. Rockville: Agency for Healthcare Research and Quality; 2001. AHRQ Pub. No. 02-R0203. 2. Gao J, Moran E, Li YF, et al. Predicting potentially avoidable hospitalizations. Med Care 2014 Feb;52(2):164-71 3. Chartbook on Care Coordination: Potentially Avoidable Hospitalizations. Agency for Healthcare Research and Quality. https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure3.html Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Inpatient Reliance Ratio Versus Emergency Department Reliance Ratio in a Sickle Cell Disease Medical Home

Background: The Emergency Department (ED) Reliance Ratio (ERR, defined as ED visits/ED + ambulatory + inpatient visits) measures the percentage of all health care visits that occur in the ED in relation to primary care, including avoidable ED visits, and may therefore discriminate among high-ED-user populations. Adults with sickle cell disease (SCD) are known to have high ERR (by convention, >0.33), likely driven by a complex mix of factors. Like in other ambulatory-care-sensitive conditions, intense SCD ambulatory case management may drive down the ERR. But we found no validated measure of hospital utilization percentage analogous to the ERR. We therefore created the inpatient reliance ratio (IRR, defined as inpatient visits/ED + ambulatory + inpatient visits), as the percentage of all health care visits that occur in the hospital in relation to primary care and ED care, including avoidable hospital visits. We tested the performance of the ERR versus the IRR in an adult SCD sample. Method: In 2018, as part of a multi-component intervention in an SCD Adult Medical Home, we assigned Patient Navigators (PNs), as case managers to each of the program's top 50 highest utilizers, but also began periodically managing the remaining medical home patients ad hoc. Services provided included behavioral health services, dedicated inpatient care, an infusion unit, and inpatient and ED individualized care plans. The study sample was Adult SCD patients at Virginia Commonwealth University from 2011-2021 (annual N's from 299 to 641). Using Analysis of Variance, we studied the effect of the intervention over time on total annual charges, the annual ERR, and the annual IRR. We also performed Spearman's correlations associating annual total charges with either annual ERR or annual IRR. Last, we performed linear regression with annual total charges as the outcome variable (linearly distributed), to test the relative predictive contribution of ERR vs. IRR. Results: (Figure 1) After increasing steadily from 2011-2017 pre-program onset, both the annual ERR and the annual IRR decreased roughly successively from 2017-21 (ANOVA p-value=0.0089 for ERR, ANOVA p-value=0.0002 for IRR). Annual total charges correlated strongly with ERR (Spearman R=0.44, P<0.0001) but more strongly with annual IRR (Spearman R=0.64, P-value<0.0001). Similarly, linear regression indicated that IRR contributed more strongly to annual total charges than did ERR (beta coefficients = 97906 vs 23175). Conclusion: We demonstrate that the IRR, similar to the ERR, appears to be a measure of avoidable care: It varies as a function of total costs, but it is sensitive to intense ambulatory case management. It more closely correlates with total costs and more closely predicts total costs than the ERR. The benchmark for what makes a high or low IRR has not been defined as it has for ERR. But future studies could further show its relationship to utilization management and get population norms to set an appropriate management goal for the IRR. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Characterization of potentially avoidable neurological emergency department visits at a large urban public hospital

This study characterized potentially avoidable neurological emergency department (ED) visits at a large urban public hospital. This was a retrospective review of Parkland Health (Dallas, TX) data from May 15, 2021, to July 15, 2021. The study population included encounters discharged home from the ED with any of the following: a primary neurological ED diagnosis, a neurological consultation in the ED, or a neurology clinic referral placed during the ED encounter. Neurovascular, strokelike, acute trauma, and nonneurological cases were excluded. The primary outcome was the number of ED visits by diagnosis category. A total of 965 ED discharge encounters met study criteria as potentially avoidable neurological ED visits, far higher than total neurology-related admissions over the same 2-month period. Headache (66%) and seizure/epilepsy (18%) syndromes were the most common. Thirty-five percent of all cases had neurology involvement in either the ED or the outpatient setting. This was lowest for headache (19%). The revisit rate within 3 months of the index ED visit was 29%, and it was highest for seizures/epilepsy (48%). Potentially avoidable nonvascular neurological ED visits occur frequently, especially for headache and seizure disorders. This study highlights the need for quality improvement and delivery innovation initiatives to optimize the site of care for patients with chronic neurological conditions.