Lower Emergency Department Utilization Research Articles

What value do teaching hospitals provide commercial beneficiaries when in an ACO?

The number of commercial beneficiaries cared for by accountable care organizations (ACOs) is growing, but the literature examining their trends is nascent. We examined commercial claims data from 2019 to 2021 to compare beneficiaries attributed to participants in Medicare Shared Savings Program ACOs with and without a major teaching hospital. We calculated mortality and spending by setting for each ACO type by year. Compared with per-beneficiary rates at nonteaching ACOs, major teaching ACOs have lower mortality rates by up to 2.2 percentage points depending on the patient age group, $283 lower inpatient spending, and lower emergency department utilization in inpatient (-0.008) and outpatient (-0.013) settings, as well as $146 higher overall outpatient spending. Upward trends in mortality and beneficiary risk scores across both ACO types show disruption to health outcomes during COVID-19. These results provide evidence that ACOs with major teaching hospitals may be more likely to achieve the value-based goals of ACOs. Means to accomplish those goals may include avoiding higher-intensity care and supporting access to lower-cost alternatives where clinically appropriate, such as reducing inpatient and emergency department stays by delivering timely, high-quality outpatient care.

Comparison of Short-Term Health Care Utilization Between Telemedicine-Delivered vs In-Person Care Visits for Heart Failure

BackgroundPatients with heart failure (HF) are a medically complex population with frequent hospitalizations. Downstream health care utilization following primary care delivered by telemedicine compared to in-person is unknown. ObjectivesThe purpose of this study was to understand differences in return in-person visits, emergency department (ED) encounters, and hospitalizations following a telemedicine vs an in-person primary care visit for patients with HF seen for a HF-related complaint. MethodsThis was an observational study of all primary care visits for HF from January 1, 2022, to December 31, 2022, in an integrated health care delivery system. We compared 7-day in-person follow-up visits, ED visits, and hospitalizations (all-cause and HF-specific) by index visit type. ResultsWe included 3,902 primary care visits with a primary diagnosis of HF. Most visits utilized telephone or video visits (58.4% total; 44.9% telephone, 13.5% video). After adjustment, telephone visits were associated with more in-person follow-up visits (6.14% vs 4.20%; adjusted OR: 1.08-2.21; P < 0.05) but fewer ED visits (6.12% vs 8.07%; adjusted OR: 0.55-0.97; P < 0.05) compared to in-person visits. Most hospitalized patients (74%) had an admitting diagnosis of HF. There was no difference between 7-day all-cause hospitalization following telephone or video visits compared to in-person visits. ConclusionsMost patients used telemedicine to address HF-specific primary care concerns. Telephone visits were associated with slightly higher short-term in-person primary care follow-up but lower ED utilization. Overall, downstream ED visits and hospitalizations were low. Telephone and video visits appear to offer safe alternatives to in-person care for HF-related primary care and are a promising health care delivery strategy

Race/ethnicity and socioeconomic position in emergency department utilization in patients with hepatocellular carcinoma.

Aim: Evaluate the association of race/ethnicity and socioeconomic position (SEP) on emergency department (ED) visits for patients with hepatocellular carcinoma (HCC), which may reflect access to and quality of cancer care.Materials & methods: Patients with HCC identified from a commercial multi-payer claims database between 2015 and2018 were matched to near-neighborhood social determinants of health (SDOH) and stratified by race/ethnicity and SEP (proxied by annual household income). Analyses evaluated the effect of race/ethnicity and SEP on ED utilization, adjusting for SDOH, demographic and clinical characteristics using multivariable regression methods.Results: A total of22,247 patients were included. Black and Hispanic patients had 43and 18% higher ED utilization than White patients at higher-income levels (p<0.01); these differences were nonsignificant at lower-income. Regardless of income level, Asian patients had lower ED utilization.Conclusion: Further research on the intersectionality between race/ethnicity, SEP and other SDOH may guide structural-level interventions to address health inequities.

Sociodemographic characteristics and emergency department visits and inpatient hospitalizations for atopic dermatitis in Ontario: a cross-sectional study

BackgroundSome jurisdictions experience sociodemographic disparities in atopic dermatitis care, including emergency department visits, but data from Canada are limited. Our objectives were to estimate the prevalence of atopic dermatitis in Ontario and to identify sociodemographic factors associated with emergency department visits and hospitalizations for this condition.MethodsWe conducted a cross-sectional analysis of patients in the Electronic Medical Record Primary Care database linked with administrative health data for Ontario, Canada. We estimated period prevalence and health service utilization for atopic dermatitis from 2005 to 2015. We used multivariable log-binomial regression to calculate adjusted risk ratios (RRs) and 95% confidence intervals (CIs) for associations between local dermatologist density and the proportion of emergency department visits and hospitalizations for atopic dermatitis.ResultsAmong 249 984 patients, we identified 7812 with atopic dermatitis (period prevalence 2005–2015: 3.1%). Almost all physician visits for atopic dermatitis were to primary care physicians (> 99%). For every additional dermatologist per 100 000 population, the proportions of emergency department visits and hospitalizations for atopic dermatitis increased by 29% (RR 1.29, 95% CI 1.05–1.57). This relationship occurred in and around Toronto but was not consistent across the province.InterpretationIn Ontario, higher dermatologist density was not associated with lower emergency department utilization and hospitalization for atopic dermatitis; the association varied in different locales with similar dermatologist densities. Strategies to improve access to care for atopic dermatitis should be tailored to local contexts.

Oncology rapid assessment clinic and effect on ED visits.

258 Background: The use of the Emergency Department (ED) by oncology patients for lower acuity issues is common. Oncology Rapid Assessment Clinics (ORAC) may play a key role in reducing ED visits among oncology patients. We analyzed whether the advent of ORAC was associated with lower ED utilization by patients receiving cancer care at University of Chicago Medical Center (UCMC). Methods: UCMC opened its ORAC in March 2019 to provide supportive care and symptom management to cancer patients who needed acute medical issues addressed. To identify active cancer patients, we identified those that had either a forward or reverse 9 month rolling count of greater than or equal to 2 Outpatient Clinic Visits (complete or future). Of all those patients, we identified any ED visit made within the time period considered Pre-ORAC (6/2018-2/2019) and Post-ORAC (6/2019-2/2020). To determine effect of ORAC on ED utilization, we performed t-test comparison of rates. Results: A total of 9,043 unique patients were seen in the Pre-ORAC period and 8,753 in the Post-ORAC period. Predominant cancers seen in both periods were Breast, Lung/Head &amp; Neck, GI, Lymphoma/Leukemia, GU, and Multiple Myeloma. The ED visit rate was 0.252 (2279/9043) in Pre-ORAC period and 0.237 (2075/8753) in the Post-ORAC period (p = 0.02). Conclusions: There was a decrease in ED visit rates for oncology patients cared for by UCMC in the immediate period after the opening of the ORAC clinic. More substantial declines are expected in the future as the capacity and efficiency of the ORAC clinic grows and the concept is socialized among cancer providers.

Effects of Maryland's global budget revenue model on emergency department utilization and revisits.

In 2014, Maryland (MD) implemented a "global budget revenue" (GBR) program that prospectively sets hospital budgets. This program introduced incentives for hospitals to tightly control volume and meet budget targets. We examine GBR's effects on emergency department (ED) visits, admissions, and returns. We performed an interrupted time-series analysis with difference-in-differences comparisons using 2012 to 2015 Healthcare Cost Utilization and Project data from MD, New York (NY), and New Jersey (NJ). We examined GBR's effects on ED visits/1,000 population, admissions from the ED, and ED returns at 72h and 9days. We also examined rates of admission, intensive care unit (ICU) stay, and in-hospital mortality among returns. To evaluate racial/ethnic and payer outcome disparities among ED returns, we performed a triple differences analysis. ED visits decreased with GBR adoption in MD relative to NY and NJ, by five and six visits/1,000 population, respectively. ED admissions declined relative to NY and NJ, by 0.6% and 1.8%, respectively. There was also a post-GBR decline in ED returns by 0.7%. Admissions among returns declined by 2%, while ICU and in-hospital mortality among returns remained relatively stable. ED return outcomes varied by racial/ethnic and payer group. Non-Hispanic Whites and non-Hispanic Blacks experienced a similar decline in returns, while returns remained unchanged among Hispanics/Latinos, widening the disparity gap. Payer group disparities between privately insured and Medicare, Medicaid, and uninsured individuals improved, with the disparity reduction most pronounced among the uninsured. GBR adoption was associated with lower ED utilization and admissions. ED returns and admissions among returns also decreased, while mortality and ICU stays among returns remained stable, suggesting that GBR has not led to adverse patient outcomes from fewer admissions. However, changes in ED return disparities varied by subgroup, indicating that improvements in care transitions may be uneven across patient populations.

Primary Care Comprehensiveness and Care Coordination in Robust Specialist Networks Results in Lower Emergency Department Utilization: A Network Analysis of Medicaid Physician Networks.

Background: Care coordination is an essential and difficult to measure function of primary care. Objective: Our objective was to assess the impact of network characteristics in primary/specialty physician networks on emergency department (ED) visits for patients with chronic ambulatory care sensitive conditions (ACSCs). Subjects and Measures: This cross-sectional social network analysis of primary care and specialty physicians caring for adult Medicaid beneficiaries with ACSCs was conducted using 2009 Texas Medicaid Analytic eXtract (MAX) files. Network characteristic measures were the main exposure variables. A negative binomial regression model analyzed the impact of network characteristics on the ED visits per patient in the panel. Results: There were 42 493 ACSC patients assigned to 5687 primary care physicians (PCPs) connected to 11 660 specialist physicians. PCPs whose continuity patients did not visit a specialist had 86% fewer ED visits per patient in their panel, compared with PCPs whose patients saw specialists. Among PCPs connected to specialists in the network, those with a higher number of specialist collaborators and those with a high degree of centrality had lower patient panel ED rates. Conclusions: PCPs providing comprehensive care (ie, without specialist consultation) for their patients with chronic ACSCs had lower ED utilization rates than those coordinating care with specialists. PCPs with robust specialty networks and a high degree of centrality in the network also had lower ED utilization. The right fit between comprehensiveness of primary care, care coordination, and adequate capacity of specialty availability in physician networks is needed to drive outcomes.

Impact of an oncology urgent care clinic on emergency department rates.

6615 Background: Oncology-specific urgent care clinics (UCC) may play a key role in reducing unscheduled emergency department (ED) visits among patients with cancer. We sought to determine if establishment of an Oncology UCC was associated with lower ED utilization among patients receiving cancer care at Yale’s Smilow Cancer Hospital (SCH) and two nearby, integrated community practices. Methods: SCH opened its UCC in April 2017 to provide supportive care and symptom management for patients with cancer who need acute medical attention outside of regular clinic visits. We identified patients who had at least one visit with an oncology provider during the Pre-UCC period (9/1/16 – 12/31/16) or Post-UCC period (9/1/17 – 12/31/17) and received chemotherapy within a year preceding their provider visit. For each patient, we captured all ED visits in a four-month window starting from their last provider visit in each study period. The ED visit rate for both periods was defined as the total number of ED visits divided by the total number of unique patients in the period. To determine the impact of the UCC on ED utilization, we evaluated the absolute difference in the ED visit rate between the Pre- and Post-UCC period using a two-sample t test. Results: There were 3,754 patients in the Pre-UCC period and 4,734 patients in the Post-UCC period. In the full study sample, the mean age was 62.9 and most common cancer types were Hematologic, Gastrointestinal, and Breast. Prior to opening the UCC, the ED visit rate was 0.27 per unique patient. After opening the UCC, we found a 13.9% relative decrease in the overall ED visit rate from 0.27 to 0.23 (p = 0.02). The SCH patient ED visit rate declined by 12.5% (p = 0.03) and the community practice rate declined by 37.1%; however, the latter decline was not statistically significant, potentially due to a small sample size (p = 0.19). Conclusions: Our study found a decrease in the ED visit rate after the opening of an Oncology UCC. An urgent care strategy for cancer centers may serve as an efficient way to manage patients while minimizing ED use. [Table: see text]

Quality of Care for Children With Medical Complexity: An Analysis of Continuity of Care as a Potential Quality Indicator

ObjectiveTo examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination. MethodsWe measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. For a subset of 186 of these CMC a caregiver survey was used to measure care coordination quality (using items adapted from the Consumer Assessment of Healthcare Providers and System Adult Health Plan Survey) and family impact (using items adapted from the National Survey of Children with Special Health Care Needs). Multivariable regression was used to examine the relationship between continuity, entered as a continuous variable ranging from 0 to 1, and the outcomes. ResultsThe median continuity was 0.27 (interquartile range [IQR], 0.12–0.48) in the administrative data cohort and 0.27 (IQR, 0.14–0.43) in the survey cohort. Compared with children with a continuity score of 0, children with a score of 1 had lower odds of having ≥1 ED visit (odds ratio, 0.65; 95% confidence interval [CI], 0.46–0.93; P = .017) and their caregivers reported higher scores for the measure of receipt of care coordination (β = 35.2 on a 0–100 scale; 95% CI, 11.5–58.9; P = .004). There was no association between continuity and family impact. ConclusionsContinuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.

Relationship between office-based provider visits and emergency department encounters among publicly-insured adults with epilepsy

IntroductionThe proportion of adults with epilepsy using the emergency department (ED) is high. Among this patient population, increased frequency of office-based provider visits may be associated with lesser frequency of ED encounters, and key patient features may be linked to more ED encounters. MethodsWe analyzed the Medical Expenditure Panel Survey Household Component (MEPS-HC) dataset for years 2003–2014, which represents a weighted sample of 842,249 publicly-insured US adults aged ≥18years. The Hurdle Poisson model that accommodates excess zeros was used to estimate the association between office-based and ED visits. ResultsAnnual mean ED and office-based visits for publicly-insured adults with epilepsy were 0.70 and 10.8 respectively. Probability of at least one ED visit was 0.4% higher for every unit of office-based visit. Individuals in the high income category were less likely to visit the ED at least once while women with epilepsy had a higher likelihood of visiting the ED at least once. Among those who visited the ED at least once, there was a 0.3% higher likelihood of visiting the ED for every unit of office-based visit. Among individuals who visited the ED at least once, being aged 45–64years, residing in the West, and the year 2011/14 were associated with higher ED visits. ConclusionIn this representative sample of publicly-insured adults with epilepsy, higher frequency of office visits was not associated with lower ED utilization, which may be due to underlying greater disease severity or propensity for more treatment complications.

Federally Qualified Health Center Access and Emergency Department Use Among Children.

To determine whether increasing access to federally qualified health centers (FQHCs) in California was associated with decreased rates of emergency department (ED) use by children without insurance or insured by Medicaid. We combined several data sets to longitudinally analyze 58 California counties between 2005 and 2013. We defined access to FQHCs by county using 2 measures: FQHC sites per 100 square miles between 2005 and 2012 and percentage of Medicaid-insured and uninsured children served by FQHCs from 2008 to 2013. Our outcome was rates of ED use by uninsured or Medicaid-insured children ages 0 to 18 years. To determine the effect of changes in FQHC access on the outcome within a county over time, we used negative binomial models with county fixed effects and controls for preselected time-varying county characteristics and secular trends. Increased geographic density of FQHC sites was associated with ≤18% lower rates of ED visits among Medicaid-insured children and ≤40% lower ED utilization among uninsured children (P = .05 and P < .01, respectively). However, the percentage of Medicaid-insured and uninsured children seen at FQHCs was not associated with any significant change in ED visit rates among Medicaid-insured or uninsured children. Whereas increased geographic FQHC access was associated with lower rates of ED use by uninsured children, all other measures of FQHC access were not associated with statistically significant changes in pediatric ED use. These results provide community-level evidence that expanding FQHCs may have a limited impact on pediatric ED use, suggesting the need to explore additional factors driving ED utilization.

The Effectiveness of Pharmacist-Provided Telephonic Medication Therapy Management on Emergency Department Utilization in Home Health Patients.

Preventable emergency department (ED) use may be targeted with interventions for improving the medication use process, as medication misadventures and non-adherence frequently cause preventable ED utilization. One intervention that could prevent ED visits is Medication Therapy Management (MTM). To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing emergency department utilization within a Medicare insured home health population. This was a secondary analysis of data from a cluster-randomized controlled trial examining re-hospitalizations among Medicare insured patients within forty randomly selected, geographically diverse, home-health centers. The intervention consisted of an initial telephonic medication reconciliation with a pharmacy technician, a telephonic pharmacist-provided medication review, and follow-up pharmacist phone calls. The primary outcome of this analysis was 60-day all-cause emergency department utilization. Patients' baseline risk of ED utilization was calculated, and patients were stratified into quartiles based on their risk of ED utilization. Adjusted odd ratios of ED utilization were calculated. Data from 656 patients (intervention n=297, usual care n=359) were available for this study. Overall, the MTM intervention was not associated with 60-day ED use, as 24.4% of intervention patients and 25.1% of usual care patients utilized the ED (Adjusted Odds Ratio=1.11; 95% CI: 0.79-1.57). However, there was lower ED utilization among patients in the lowest risk-quartile (Adjusted Odds Ratio=2.52; 95% CI: 1.15-5.49; p= 0.02). This pharmacist-delivered telephonic medication therapy management program did not decrease ED utilization overall in a Medicare insured home health population, but may further reduce the risk of ED utilization among patients who are at lower risk of utilization.

Residential Stability Reduces Unmet Health Care Needs and Emergency Department Utilization among a Cohort of Homeless and Vulnerably Housed Persons in Canada.

This study examined the association of housing status over time with unmet physical health care needs and emergency department utilization among homeless and vulnerably housed persons in Canada. Homeless and vulnerably housed individuals completed interviewer-administered surveys on housing, unmet physical health care needs, health care utilization, sociodemographic characteristics, substance use, and health conditions at baseline and annually for 4years. Generalized logistic mixed effects regression models examined the association of residential stability with unmet physical health care needs and emergency department utilization, adjusting for potential confounders. Participants were from Vancouver (n = 387), Toronto (n = 390), and Ottawa (n = 396). Residential stability was associated with lower odds of having unmet physical health needs (adjusted odds ratio (AOR), 0.82; 95% confidence interval (CI), 0.67, 0.98) and emergency department utilization (AOR, 0.74; 95% CI, 0.62, 0.88) over the 4-year follow-up period, after adjusting for potential confounders. Residential stability is associated with fewer unmet physical health care needs and lower emergency department utilization among homeless and vulnerably housed individuals. These findings highlight the need to address access to stable housing as a significant determinant of health disparities.

Site of Treatment for Non-Urgent Conditions by Medicare Beneficiaries: Is There a Role for Urgent Care Centers?

BackgroundThere is limited information on where and how often Medicare beneficiaries seek care for non-urgent conditions when a physician office visit is not available. Emergency departments are often an alternative site of care, and urgent care centers have now also emerged to fill this need. The purpose of the study was to characterize the site of care for Medicare beneficiaries with non-urgent conditions; the relationship between physician office, urgent care center, and emergency department utilization; and specifically the role of urgent care centers. MethodsThe study is a retrospective, cross-sectional study of fee-for-service Medicare beneficiaries for fiscal year 2012. The main outcome was rate and geographic variation of urgent care center, emergency department, or physician office utilization. ResultsCare for non-urgent conditions most commonly occurred in physician offices (65.0 per 100 beneficiaries). In contrast, urgent care centers (6.0 per 100 beneficiaries) were a more common site of care than emergency departments (1.0 per 100 beneficiaries). Overall, 83% of non-urgent visits were physician offices, 14% urgent care centers, and 3% emergency departments. There was regional variation in urgent care center, emergency department, and physician office utilization for non-urgent conditions. Areas of higher emergency department utilization correspond to areas of lower urgent care center and physician office utilization, whereas areas of higher urgent care center utilization had lower emergency department utilization. ConclusionsUrgent care centers are an important site of care for Medicare beneficiaries for non-urgent conditions. There is regional variation in the use of urgent care centers, emergency departments, and physician offices, with areas of low urgent care center utilization having higher emergency department utilization. The utilization of urgent care centers for treatment for non-urgent conditions may decrease emergency department utilization.

The Effect of the Vermont Diabetes Information System on Inpatient and Emergency Department Use: Results from a Randomized Trial

Objective To describe the effect of the Vermont Diabetes Information System (VDIS) on hospital and emergency department use. Data Source Statewide discharge database. Study Design Randomized controlled trial of a decision support system for 7412 adults with diabetes and their 64 primary care providers. Data Collection/Data Extraction Charges and dates for hospital admissions and emergency department care in Vermont during an average of 32 months of observation. Data from New York hospitals were not available. Results Patients randomized to VDIS were admitted to the hospital less often than control subjects (0.17 admissions vs 0.20; P = .01) and generated lower hospital charges ($3113 vs $3480; P = .019). VDIS patients also had lower emergency department utilization (0.27 visits vs 0.36; P <.0001) and charges ($304 vs $414; P <.0001). The intervention was particularly effective in men and in older subjects. Conclusions Despite data limitations that tended to reduce the apparent effect of the system, this randomized, controlled trial showed that VDIS reduces hospitalization and emergency department utilization and expenses.

Is greater continuity of care associated with less emergency department utilization?

The benefits of continuity of care (COC) have not been firmly established for pediatric patients. To assess whether greater COC is associated with lower emergency department (ED) utilization. Outpatient teaching clinic at Children's Hospital and Regional Medical Center, Seattle, WA. All 785 Medicaid managed care children ages 0 to 19 years followed at Children's Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits. Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits. Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53-0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50-0.80]). Resident COC was not significantly associated with ED use. Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.