Greater Emergency Department Use Research Articles

Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients

Abstract: Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.

Lifetime History of Sexual Assault and Emergency Department Service Use among Women Veterans.

Although sexual assault survivors are at increased risk for adverse physical and mental health outcomes and tend to use more health care services, little is known about women veterans' lifetime history of experiencing sexual assault (lifetime sexual assault [LSA]) and emergency department (ED) use. We sought to examine associations between experiencing LSA, mental health diagnoses, and ED use among women veterans. Computer-assisted telephone interviews were conducted with 980 women veterans enrolled at two Veterans Affairs (VA) Medical Centers to assess history of experiencing LSA, health care use, sociodemographic characteristics, and military history. Administrative data provided VA use, mental health, and medical diagnoses. Logistic regression analyses examined associations between experiencing LSA and mental health diagnoses and past 5-year ED use. Classification tree analysis characterized ED use in participant subgroups. Sixty-four percent of participants visited a VA or non-VA ED during the previous 5years. Women veterans with histories of mental health diagnoses and who experienced sexual assault had an odds of ED use almost two times greater than those with no history of experiencing sexual assault and no mental health diagnoses. The odds were similar for experiencing attempted (adjusted odds ratio, 1.85) and completed (adjusted odds ratio, 1.95) sexual assault. Classification tree analysis identified reliance on VA care and the composite variable representing experiencing LSA and mental health diagnoses as factors that best discriminated ED users from nonusers. Experiencing LSA is associated with greater ED use in women veterans enrolled in the VA. Whether finding this reflects greater emergent health care needs, suboptimal access and treatment for conditions that could be managed in other settings, lack of health care coordination, or some combination of these factors is unclear.

Are There Differences in Pediatric Psychiatric Emergency Department Patients Related to Utilization Frequency?

The increasing frequency of visits to the pediatric psychiatric emergency department in the United States signals a need for a better understanding of factors contributing to more frequent utilization. This study examined characteristics of patients associated with higher utilization of the pediatric psychiatric emergency department to increase understanding of this group of patients. This was a retrospective observational study. Data were abstracted from the electronic medical record system from January 2012 to December 2017 for patients with a completed mental health consultation. There were 8504 total encounters for 6950 unique patients during this period. Analyses were conducted to test associations between maximum number of visits in any 1-year period for each patient and demographic and clinical factors. Younger age was independently associated with greater mean number of visits within any 1 year. No independent associations were found between maximum number of visits within 1 year and sex, race, language, insurance type, distance from emergency department, time spent in the emergency department, or reason for visit. The greater emergency department use by younger children found in this study may be an indicator of insufficient treatment at other levels of care. Additional research examining more demographic variables and demographic characteristics in greater detail is needed to fully characterize the most frequent users of costly pediatric psychiatric emergency department care.

Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization.

Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1year with an established medical home. Retrospective cohort study using linked administrative data for infants ≥ 34weeks' gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits. Among 10,363 infants, three WCC latent classes were identified: "Adherent" (83.4% of the cohort), "Intermediate" (9.7%), and "Decreasing adherence" (7.0%). Sixty-one percent of the sample had ≥ 1 ED visit in the first 12months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, "Intermediate" and "Decreasing adherence" WCC patterns were associated with a lower incident rate of ED visits compared with the "Adherent" pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001). Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions.

ED Visits on the Rise for People With Dementia

Emergency department (ED) visits in the last year of life for people with dementia are common and increasing in the United Kingdom, according to a retrospective cohort study linking clinical and administrative data. The study also found that being a resident in a care home (both residential care homes with personal care only, and care homes with nursing care) was associated with a reduced likelihood of ED attendance, which suggests that care home residence “might ‘protect’ patients against transitions in care setting close to death,” said Katherine E. Sleeman, PhD, of King’s College London, and her associates. The finding that more than three-quarters of patients (78.6%) with dementia had at least one ED visit in their last year of life is similar to data from the United States and Australia, the investigators said, so policy makers should study and consider not only place of death but a broader range of indicators of the quality of end-of-life care. Dying out of the hospital has been a policy focus in the United Kingdom, but “the place of death … doesn’t tell us about the care they received during their last weeks and months,” the investigators reported (Alzheimer’s Dement 2018;14:20–27). The study also found that being a resident in a care home … was associated with a reduced likelihood of ED attendance. Their study linked electronic medical record data from a large mental health care provider covering four boroughs of South London with national mortality and hospital use data, and focused on the last year of life. The closer patients were to death, the more likely they were to visit EDs; approximately one-quarter of all ED visits occurred in the last month of life. Of the 4,867 patients in the cohort, 44.5% had at least one ED visit in the last month of life, and 20.9% had at least one visit in the last week of life. The mean number of ED attendances per patient in the last year of life increased from 1.6 during 2008–2009 to 2.4 during 2012–2013. Almost all ED visits (91%) were by ambulance, and almost half occurred “out of hours,” which suggests that the visits were precipitated by an acute crisis, the authors said. Approximately 75% of the 1,783 care home residents in the cohort had at least one ED visit in the last year of life, compared with 81% of the 3,084 patients who did not live in a care home. Care home residence remained associated with less ED use in a multivariable model of analysis. Factors associated with greater ED use included male gender, higher cognitive function (Mini-Mental State Examination score), diagnosis of vascular dementia, and living in less affluent areas — the latter of which has been shown in prior research to impact access to palliative care/hospice services, the investigators noted. Investigators were limited by the lack of any information regarding patients’ preferences or wishes, the presence or absence of advance directives, or the decision-making process leading to ED attendance. “For people with dementia, high rates of ED attendance near the end-of-life may indicate inadequate availability of community care, a paucity of advance directives, or lack of focus on patients’ quality of life,” the investigators wrote. The most common diagnosis was Alzheimer’s disease (40.4%) followed by vascular dementia (25.4%). Christine Kilgore is a freelance writer in Falls Church, VA.

Factors associated with emergency department useamong veteran psychiatric patients.

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n=226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.

Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

ObjectivesTo evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.DesignRetrospective cohort study.SettingDepartment of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.ParticipantsMedicare‐eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007–08 (baseline period) (N = 243,881).MeasurementsTwo measures of longitudinal continuity were estimated using merged VA–Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.ResultsThe incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02–1.07), intermediate (IRR = 1.04, 95% CI = 1.02–1.07), and low (IRR = 1.06, 95% CI = 1.03–1.09) UPC than in those with very high UPC (0.9–1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01–1.07), intermediate (OR = 1.03, 95% CI = 1.00–1.06), and low (OR = 1.04, 95% CI = 1.01–1.07) UPC were also more likely to be hospitalized during follow‐up. Results were similar for MMCI continuity scores.ConclusionEven slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

Rural Medicare Beneficiaries have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge

Rural Medicare Beneficiaries have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge

Rural Medicare Beneficiaries Have Fewer Follow-up Visits and Greater Emergency Department Use Postdischarge.

Hospitals are focused on improving postdischarge services for older adults, such as early follow-up care after hospitalization to reduce readmissions and unnecessary emergency department (ED) use. Rural Medicare beneficiaries face many barriers to receiving quality care, but little is known about their postdischarge care and outcomes. We hypothesize that rural Medicare beneficiaries compared with urban beneficiaries, will have fewer follow-up visits, and a greater likelihood of readmission and ED use. We conducted a retrospective analysis of elderly Medicare beneficiaries discharged home using the Medicare Current Beneficiary Survey, Cost and Use files, 2000-2010. Multivariate Cox proportional hazard models were used to assess the risk of rural residency on readmission, ED use, and follow-up care up to 30 days' postdischarge. Covariates include demographic, health, and hospital-level characteristics. Compared with urban beneficiaries, Medicare beneficiaries living in isolated rural settings had a lower rate of follow-up care [hazard ratio (HR)=0.81, P<0.001]. Beneficiaries in large and small rural settings had a greater risk of an ED visit compared with urban beneficiaries (HR=1.44, P<0.001; HR=1.52, P<0.01). Rural beneficiaries did not have a greater risk of readmission, though risk of readmission was higher for beneficiaries discharged from hospitals in large and small rural settings (HR=1.33, P<0.05; HR=1.42, P<0.05). This study provides evidence of lower quality postdischarge care for Medicare beneficiaries in rural settings. As readmission penalties expand, hospitals serving rural beneficiaries may be disproportionately affected. This suggests a need for policies that increase follow-up care in rural settings.

Potentially Preventable Use of Emergency Services

Limited health literacy is a barrier for understanding health information and has been identified as a risk factor for overuse of the emergency department (ED). The association of health literacy with access to primary care services in patients presenting to the ED has not been fully explored. To examine the relationship between health literacy, access to primary care, and reasons for ED use among adults presenting for emergency care. Structured interviews that included health literacy assessment were performed involving 492 ED patients at one Southern academic medical center. Unadjusted and multivariable logistic regression models assessed the relationship between health literacy and (1) access to a personal physician; (2) doctor office visits; (3) ED visits; (4) hospitalizations; and (5) potentially preventable hospital admissions. After adjusting for sociodemographic and health status, those with limited health literacy reported fewer doctor office visits [odds ratio (OR)=0.6; 95% confidence interval (CI), 0.4-1.0], greater ED use, (OR=1.6; 95% CI, 1.0-2.4), and had more potentially preventable hospital admissions (OR=1.7; 95% CI, 1.0-2.7) than those with adequate health literacy. After further controlling for insurance and employment status, fewer doctor office visits remained significantly associated with patient health literacy (OR=0.5; 95% CI, 0.3-0.9). Patients with limited health literacy reported a preference for emergency care, as the services were perceived as better. Among ED patients, limited health literacy was independently associated with fewer doctor office visits and a preference for emergency care. Policies to reduce ED use should consider steps to limit barriers and improve attitudes toward primary care services.

Risk Factors for Increased ED Utilization in a Multinational Cohort of Children With Sickle Cell Disease

The objective was to identify clinical, social, and environmental risk factors for increased emergency department (ED) use in children with sickle cell disease (SCD). This study was a secondary analysis of ED utilization data from the international multicenter Silent Cerebral Infarct Transfusion (SIT) trial. Between December 2004 and June 2010, baseline demographic, clinical, and laboratory data were collected from children with SCD participating in the trial. The primary outcome was the frequency of ED visits for pain. A secondary outcome was the frequency of ED visits for acute chest syndrome. The sample included 985 children from the United States, Canada, England, and France, for a total of 2,955 patient-years of data. There were 0.74 ED visits for pain per patient-year. A past medical history of asthma was associated with an increased risk of ED utilization for both pain (rate ratio [RR] = 1.28, 95% confidence interval [CI] = 1.04 to 1.58) and acute chest syndrome (RR = 1.60, 95% CI = 1.03 to 2.49). Exposure to environmental tobacco smoke in the home was associated with 73% more ED visits for acute chest syndrome (RR = 1.73, 95% CI = 1.09 to 2.74). Each $10,000 increase in household income was associated with 5% fewer ED visits for pain (RR = 0.95, 95% CI = 0.91 to 1.00, p = 0.05). The association between low income and ED utilization was not significantly different in the United States versus countries with universal health care (p = 0.51). Asthma and exposure to environmental tobacco smoke are potentially modifiable risk factors for greater ED use in children with SCD. Low income is associated with greater ED use for SCD pain in countries with and without universal health care.

Health Insurance Status Change and Emergency Department Use Among US Adults

Recent events have increased the instability of health insurance coverage. We compared emergency department (ED) use by newly insured vs continuously insured adults and by newly uninsured vs continuously uninsured adults. We analyzed 159,934 adult respondents to the 2004 through 2009 National Health Interview Survey. Health insurance status was categorized as newly insured (currently insured but lacked health insurance at some point during the prior 12 months) vs continuously insured and as newly uninsured (currently uninsured but had health insurance at some point during the prior 12 months) vs continuously uninsured. We analyzed the number of ED visits during the prior 12 months using multivariable Poisson regression. Overall, 20.7% of insured adults and 20.0% of uninsured adults had at least 1 ED visit. However, 29.5% of newly insured adults compared with 20.2% of continuously insured adults had at least 1 ED visit. Similarly, 25.7% of newly uninsured adults compared with 18.6% of continuously uninsured adults had at least 1 ED visit. After adjusting for demographics, socioeconomic status, and health status, recent health insurance status change was independently associated with greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% CI, 1.22-1.42 vs continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). Among newly insured adults, this association was strongest for Medicaid beneficiaries (IRR, 1.45) but was attenuated for those with private insurance (IRR, 1.24) (P < .001 for interaction). Recent changes in health insurance status for newly insured adults and for newly uninsured adults were associated with greater ED use. As policy and economic forces create disruptions in health insurance status, new surges in ED use should be anticipated.

Abuse, Outpatient Charges and Utilization, and Psychiatric Symptoms among Urban Women on Medicaid

Adult and childhood sexual and physical abuse are common and intertwined. Our objectives were to assess (1) the relationship between different forms of abuse; (2) outpatient charges and hospital and emergency department use among women with and without childhood and adult abuse; (3) psychiatric symptoms of women with and without childhood and adult abuse; and (4) the relationship between psychiatric symptoms and outpatient charges and hospital and emergency department use among a group of Medicaid-insured women seeking outpatient services in a primary care setting. We recruited female primary care patients for this cross-sectional study. Women reported childhood and adult sexual and physical abuse and anxiety, depression, and posttraumatic stress symptoms. We assessed outpatient charges through reviews of clinic records. Patients reported hospital and emergency department use. Childhood and adult sexual and physical abuse were highly interrelated. Adult sexual abuse showed a trend toward significantly greater outpatient charges. Women who had experienced physical abuse during childhood had more emergency department visits and women who experienced physical abuse as an adult had more days of hospitalization. Childhood and adult sexual abuse were both related to higher levels of anxiety, depression, and posttraumatic stress symptoms. Anxiety, depression, and posttraumatic stress symptoms were related to higher outpatient charges. Depression and posttraumatic stress symptoms were related to greater emergency department use. Women who experience abuse often have psychiatric symptoms. In our sample it was the severity of psychiatric symptoms rather than reported abuse alone that was related to outpatient charges and emergency department visits.

Caregiver Adherence to Follow-Up After an Emergency Department Visit for Common Pediatric Illnesses

Access to primary care is often a problem for children living in urban areas and the rate of emergency department (ED) use can be high. For acute childhood illnesses, primary care follow-up is often recommended to prevent subsequent ED visits. We conducted an observational study of 455 children with common childhood illnesses, between 6 weeks and 8 years of age, presenting to 1 of 3 EDs, and discharged to the community. ED physicians recommended that the child visit their primary care physician within 1 to 4 days of discharge (ie, "short-term" follow-up). Caregivers were surveyed during the ED index visit and after discharge to assess primary care follow-up adherence. We collected data on child and caregiver characteristics, type and severity of illness at the ED index visit, and ED return visits in the 2-month period after the ED index visit. A total of 45.3% of caregivers adhered to short-term primary care follow-up. Short-term follow-up adherence was associated with greater ED use for the same illness over the subsequent 2 months (odds ratio = 2.97; 95% confidence interval, 1.31-6.72). Subsequent ED use was greatest for children with short-term primary care follow-up and: (1) prior ED use, (2) single caregivers, (3) mild severity illnesses at the ED index visit, or (4) younger children. ED use after the initial visit did not vary by type of illness or site. There was no evidence that primary care follow-up soon after an ED visit was associated with a lower rate of subsequent ED use for common pediatric illnesses.

Placement changes and emergency department visits in the first year of foster care.

Despite great needs, many children in foster care do not receive adequate medical care. Suboptimal care may be attributable in part to placement changes, which disrupt continuity of care by both a consistent surrogate parent and potentially a primary care physician. These disruptions in turn may lead to increased use of the emergency department (ED) for outpatient care. The primary aim of this study was to test whether a greater rate of placement changes was associated with increasing use of the ED among children in their first year of foster care. The secondary aim was to compare ED visit rates with rates of visits to other ambulatory care settings among children in foster care and other Medicaid-eligible children not in foster care. Using Medicaid claims linked to foster care administrative data, we assembled a retrospective cohort of foster children in a large urban municipality from 1993 to 1996. Eligible children spent at least 9 months in a new episode of foster care and were continuously eligible for Medicaid during a 1-year follow-up period. A comparison cohort was drawn from Medicaid-eligible children not in foster care during fiscal year 1995. The dependent variable was the rate of visits to the ED or other ambulatory care settings during a 1-year follow-up period. A negative binomial model estimated visit rates to the ED and other ambulatory care settings as the number of foster care placements increased. Potential interactions were considered between age and location of service use (ED or ambulatory care setting), between age and foster care placements, and between location of service use and number of foster care placements. The 2358 children in the sample accounted for 1206 ED visits during the follow-up period; 38% experienced >or=2 placement changes. Children of all ages exhibited increasing reliance on the ED for ambulatory care services as the number of placements increased, with the rates of ED use more than doubling for all age groups beyond infancy. However, other ambulatory care service use increased by only 41% to 53%; there was much less utilization in these nonemergency settings for all children but particularly toddlers and infants, compared with their Medicaid-eligible peers. Although the absolute rates of all visits for younger foster children (<6 years of age) were low, older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group. A temporal relationship between placements and ED visits was also identified; 75% of ED visits occurring within 3 weeks of a placement change occurred in the period after a placement change. Foster children received fewer overall outpatient services than did their Medicaid-eligible peers, but with age and increasing numbers of placements, had higher visit rates and received a greater proportion of their overall outpatient care in the ED. These results suggest that poor access to nonemergent ambulatory care settings might have contributed to an increasing reliance on ED settings as foster care placements increased. The temporal relationship between ED visits and placement changes underscores the need for better health care management for foster children, particularly in the period after placement changes.

Effect of enhanced prenatal and HIV-focused services for pregnant women who are infected by human immunodeficiency virus on emergency department use.

This study examines whether the receipt of enhanced prenatal or human immunodeficiency virus (HIV) medical services is associated with in-pregnancy emergency department (ED) utilization by HIV-infected women. Medicaid and vital statistics records were linked for 1,826 women who are infected by HIV and who were delivered from 1993 to 1995 while receiving New York State Medicaid. The authors examined two types of ambulatory care--the Prenatal Care Assistance Program (PCAP) and enhanced care focused on HIV--that offer additional services in exchange for increased Medicaid reimbursement. From logistic regression models, the authors estimated adjusted associations of these types of care with ED use during pregnancy not leading directly to hospitalization. Fifty-three percent of pregnant women visited the ED. Women with ED use averaged 2.0 visits (SD = 1.1). After adjustment for demographic and substance use factors, enhanced care focused on HIV was not associated with any ED use (OR = 1.11, 95% CI 0.94, 1.30) or, among those using the ED at least once, with number of visits (P = 0.84). Interactions of receipt of PCAP care with the Adequacy of Prenatal Care Utilization Index (APNCU) and having a usual source of care in pregnancy improved model fit (P < 0.001 and P = 0.06, respectively). PCAP was associated with increased ED use only among women with inadequate APNCU or no usual source of prenatal care. Pregnant women infected with HIV receiving Medicaid relied heavily on ED care. Use of the ED was not associated with services focused on HIV but was positively associated with enhanced prenatal care. The association of enhanced prenatal care with greater ED use was curbed for women with more timely and adequate prenatal care visits or a usual source of prenatal care.