Rates Of Emergency Department Use Research Articles

The extended impact of the COVID-19 pandemic on long-term care residents in Medicare with frailty or dual Medicaid enrollment.

Although many healthcare settings have since returned to pre-pandemic levels of operation, long-term care (LTC) facilities have experienced extended and significant changes to operations, including unprecedented levels of short staffing and facility closures, that may have a detrimental effect on resident outcomes. This study assessed the pandemic's extended effect on outcomes for LTC residents, comparing outcomes 1 and 2 years after the start of the pandemic to pre-pandemic times, with special focus on residents with frailty and dually enrolled in Medicare and Medicaid. Using Medicare claims data from January 1, 2018, through December 31, 2022, we ran over-dispersed Poisson models to compare the monthly adjusted rates of emergency department use, hospitalization, and mortality among LTC residents, comparing residents with and without frailty and dually enrolled and non-dually enrolled residents. Two years after the start of the pandemic, adjusted emergency department (ED) and hospitalization rates were lower and adjusted mortality rates were higher compared with pre-pandemic years for all examined subgroups. For example, compared with 2018-2019, 2022 ED visit rates for dually enrolled residents were 0.89 times lower, hospitalization rates were 0.87 times lower, and mortality rates were 1.17 higher; 2022 ED visit rates for frail residents were 0.85 times lower, hospitalization rates were 0.83 times lower, and mortality rates were 1.21 higher. In 2022, emergency department and hospital utilization rates among long-term residents were lower than pre-pandemic levels and mortality rates were higher than pre-pandemic levels. These findings suggest that the pandemic has had an extended impact on outcomes for LTC residents.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits. This retrospective cohort study consisted of post-9/11 Veterans who enrolled in U.S. Department of Veterans Affairs (VA) care between fiscal years (FYs) 2005 and 2015. Data were obtained from the VA Corporate Data Warehouse. Incidence rates for ED visits for combat and non-combat Veterans were compared from FY 2010 to 2019 using zero-inflated negative binomial regression. The most frequent reasons for ED visits were determined using International Classification of Diseases codes. This study was approved by the Stanford Institutional Review Board. Among 1.3 million Veterans included in analyses, 70.4% had deployed to a combat zone. The mean (SD) age of our cohort was 32.6 (5.0) years and 83.5% of Veterans were male. After controlling for other factors, combat Veterans had 1.84 times the rate of ED visits compared to non-combat Veterans (95% CI, 1.83-1.85). Only combat Veterans had a mental health-related ED visit (suicidal ideations) among the top 3 reasons for ED presentation. Those who deployed to a combat zone had a significantly higher rate of ED use compared to those who did not. Further, mental health-related ED diagnoses appeared to be more prevalent in combat Veterans. These findings highlight the unique health care needs faced by combat Veterans and emphasize the importance of tailored interventions and support services for this specific population.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis.

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting. The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP. Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results. It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

Association of virtual end-of-life care with healthcare outcomes before and during the COVID-19 pandemic: A population-based study.

The use of virtual care for people at the end-of-life significantly increased during the COVID-19 pandemic, but its association with acute healthcare use and location of death is unknown. The objective of this study was to measure the association between the use of virtual end-of-life care with acute healthcare use and an out-of-hospital death before vs. after the introduction of specialized fee codes that enabled broader delivery of virtual care during the COVID-19 pandemic. This was a population-based cohort study of 323,995 adults in their last 90 days of life between January 25, 2018 and December 31, 2021 using health administrative data in Ontario, Canada. Primary outcomes were acute healthcare use (emergency department, hospitalization) and location of death (in or out-of-hospital). Prior to March 14, 2020, 13,974 (8%) people received at least 1 virtual end-of-life care visit, which was associated with a 16% higher rate of emergency department use (adjusted Rate Ratio [aRR] 1.16, 95%CI 1.12 to 1.20), a 17% higher rate of hospitalization (aRR 1.17, 95%CI 1.15 to 1.20), and a 34% higher risk of an out-of-hospital death (aRR 1.34, 95%CI 1.31 to 1.37) compared to people who did not receive virtual end-of-life care. After March 14, 2020, 104,165 (71%) people received at least 1 virtual end-of-life care visit, which was associated with a 58% higher rate of an emergency department visit (aRR 1.58, 95%CI 1.54 to 1.62), a 45% higher rate of hospitalization (aRR 1.45, 95%CI 1.42 to 1.47), and a 65% higher risk of an out-of-hospital death (aRR 1.65, 95%CI 1.61 to 1.69) compared to people who did not receive virtual end-of-life care. The use of virtual end-of-life care was associated with higher acute healthcare use in the last 90 days of life and a higher likelihood of dying out-of-hospital, and these rates increased during the pandemic.

Clinical Results of a Randomized Placebo Controlled Trial of Inhaled Mometasone to Promote Reduction in Vaso-Occlusive Events (IMPROVE-II)

Introduction: A subset of patients living with sickle cell disease (SCD) who do not meet diagnostic criteria for asthma exhibit episodic cough or wheeze (ECW), and this is associated with higher rates of vaso-occlusive pain crisis and acute chest syndrome. ECW may be caused by pulmonary inflammation from SCD. In the former IMPROVE trial, 54 patients with SCD and ECW were randomized to receive 16 weeks of placebo or mometasone furoate, an inhaled corticosteroid used to treat pulmonary inflammation. Treatment with mometasone was associated with significant reductions in daily pain, markers of hemolysis, and soluble vascular cell adhesion molecule (sVCAM) (a biomarker of disease severity in SCD) compared to placebo. The IMPROVE-II trial evaluated whether treatment with mometasone over a longer period could improve clinical and biological endpoints in non-asthmatic patients with SCD and ECW. We report here the clinical outcomes from the IMPROVE-II trial. Methods: We conducted a randomized, placebo-controlled, single-center interventional trial. Patients with SCD without asthma were randomized to receive either mometasone furoate 220 mcg or placebo inhaled powder for 48 weeks followed by a 4-week wash out. Key inclusion criteria included age > 18 years with SCD genotype HbSS/HbSβ0 at stable baseline who endorsed ECW. Patients were excluded if they had >15 emergency department (ED) visits for vaso-occlusive pain crisis in the past 12 months or if other treatments for SCD (i.e. hydroxyurea, L-glutamine) were being titrated. The primary outcome was the change in soluble vascular cell adhesion molecule (sVCAM) level with treatment. Clinical outcomes included ED visits and hospitalizations for any reason, and health care visits for acute chest syndrome, pneumonia, stroke, or transient ischemic attack, as well as daily pain (self-report 1-10 scale), and 6 Minute Walk. Adaptive covariate randomization was used to balance covariates including hydroxyurea use (yes/no), age, and previous rate of ED use. Results: A total of 80 patients were randomized and 77 received study treatment; 40 were assigned to mometasone and 37 to placebo (Figure 1). There were no significant differences between treatment groups in patient demographics (Table 1). Treatment with mometasone was associated with higher rates of acute care visits for vaso-occlusive crisis (4 (2/19) vs 1 (1/3) /patient year (50%(25%/75%), p<0.001), hospitalization for acute chest syndrome (mean 0.2 vs 0.1/patient year, p=0.05) and ED utilization (2 (1/5) vs 2 (1/4) /patient year (50%(25%/75%), p0.01). Laboratory outcomes including sVCAM are not yet resulted. Adverse events that were reported by more than 5% of patients are listed in Table 1; there was no difference between rates of adverse (<5%) events between mometasone and placebo. There were no deaths during the study. Conclusions: In individuals with SCD and ECW who do not have asthma, long-term treatment with inhaled corticosteroids did not improve clinical outcomes and may be harmful as they were associated with higher rates of acute care visits for pain crisis, ED visits, and acute chest syndrome. Further analyses of biological endpoints and clinical laboratory data are needed to fully elucidate the effects of inhaled corticosteroids in SCD.

Telemedicine Triage Model for Infusion Center-Based Management of Uncomplicated Acute Sickle Cell Pain Episodes

Introduction: Patients with sickle cell disease (SCD) develop acute episodes of pain for which they seek care in the hospital emergency department (ED). Infusion center (IC)-based care is an effective alternate treatment strategy for management of uncomplicated pain episodes. However, at our center, we could not obtain institutional buy in for dedicated IC resources. Hence, we developed a telemedicine-guided “add on” IC model, embedded within our institution's cancer infusion services. Here, we evaluate the feasibility of our telemedicine-guided IC model and its effectiveness in managing acute pain episodes and impact on SCD patient care. Methods: A multi-disciplinary team consisting of the SCD clinical team including Nurse Case Manager, Advanced Practice Provider (APP), MD and the IC team including IC leadership, IC charge RN, IC scheduler was assembled. An agreement was made between the SCD team and IC leadership that at least one “add on slot” would be made available for an acute SCD pain visit every day. A workflow was created integrating telemedicine for communication with patients and team members alike, and all team members were educated regarding the workflow (Figure 1). IC leadership was re-engaged when changes needed to be made to the workflow to accommodate more IC visits. Visit numbers for IC visits, emergency department (ED) same day discharges and inpatient (IP) hospitalizations were collected from the electronic medical record and compared for pre-IC development (Jan 1, 2017- Dec 31, 2018) and post IC (January 1, 2021 - Dec 31, 2022). Statistical analysis was performed using Graphpad/Prism assuming nonparametric distribution where applicable. Results: We were able to successfully implement our telemedicine-based IC workflow for management of acute SCD pain. Given the rapid increase in IC requests and need for accommodating more than one patient a day, we engaged nursing leadership and re-designed the workflow to identify additional “add on” slots at various IC locations in our health system, added extended hours and weekend capacity. IC visits for uncomplicated pain episodes increased nearly 9 fold, from 132 visits in the pre-IC period to 1151 visits in the post IC period. Seventeen patients used the IC in the pre-telemedicine period and 53 patients used the IC in the post-telemedicine period. The number of ED same day discharges decreased by 35.2%, from 372 visits in pre-IC phase to 241 visits in post IC period. The number of IP hospitalizations went from 281 to 278. ED visits per IC user per year decreased from 10.9 to 2.4 and IP hospitalizations per IC user per year decreased from 8.3 to 2.6. There was a positive correlation between number of IC visits and ED discharges (Spearman r 0.27, p= 0.06) and between number of IC visits and inpatient hospitalizations (Spearman r 0.4, p=0.006), indicating that the patients who were high users of IC based services also had high rates of ED use and hospitalizations. Twenty four patients who used the IC in 2022 did not have same day ED discharges, 15 patients did not have IP stays and 10 patients did not have IP or ED visits in 2022. Among these 10 patients, 8 had their first IC contact under the telemedicine triage IC model (2021-2022). Conclusions: Telemedicine based IC triage can be a successful model for delivery of IC based care for management of acute SCD pain and of great value in settings where dedicated resources are not available. The total number of ED discharges decreased after incorporation of our model, as did both ED discharges and IP hospitalizations per IC user per year. Patients with high numbers of IC visits were also high utilizers of hospital-based services. A cohort of patients were able to use the IC alone for pain management and did not use the ED or get hospitalized.

Acute care utilization and its associated determinants among patients with substance-related disorders: A worldwide systematic review and meta-analysis.

Identifying determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRDs) can improve health services to address unmet health needs. The present study aimed to identify the prevalence rates of ED use and hospitalization, and their associated determinants among patients with SRDs. Studies in English published from January 1, 1995, to December 1, 2022, were searched on PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies. The pooled prevalence rates of ED use and hospitalization among patients with SRDs were 36% and 41%, respectively. Patients with SRDs who were the most at risk of being both ED users and hospitalized were those (i) having medical insurance, (ii) having other drug and alcohol use disorders, (iii) having mental health disorders, and (iv) having chronic physical illnesses. A lower level of education increased the risk of ED use only. To decrease ED use and hospitalization, more comprehensive services may be offered to these vulnerable patients with diversified needs. Chronic care integrating outreach interventions could be more provided for patients with SRDs after discharge from acute care units or hospitals.

Maternal Emergency Department Use Before Pregnancy and Infant Emergency Department Use After Birth

Maternal emergency department (ED) use before or during pregnancy is associated with worse obstetrical outcomes, for reasons including preexisting medical conditions and challenges in accessing health care. It is not known whether maternal prepregnancy ED use is associated with higher use of the ED by their infant. To study the association between maternal prepregnancy ED use and risk of infant ED use in the first year of life. This population-based cohort study included all singleton livebirths in all of Ontario, Canada, from June 2003 to January 2020. Any maternal ED encounter within 90 days preceding the start of the index pregnancy. Any infant ED visit up to 365 days after the index birth hospitalization discharge date. Relative risks (RR) and absolute risk differences (ARD) were adjusted for maternal age, income, rural residence, immigrant status, parity, having a primary care clinician, and number of prepregnancy comorbidities. There were 2 088 111 singleton livebirths; the mean (SD) maternal age was 29.5 (5.4) years, 208 356 (10.0%) were rural dwelling, and 487 773 (23.4%) had 3 or more comorbidities. Among singleton livebirths, 206 539 mothers (9.9%) had an ED visit within 90 days before the index pregnancy. ED use in the first year of life was higher among infants whose mother had visited the ED before pregnancy (570 per 1000) vs those whose mother had not (388 per 1000) (RR, 1.19 [95% CI, 1.18-1.20]; ARD, 91.1 per 1000 [95% CI, 88.6-93.6 per 1000]). Compared with mothers without a prepregnancy ED visit, the RR of infant ED use in the first year was 1.19 (95% CI, 1.18-1.20) if its mother had 1 prepregnancy ED visit, 1.18 (95% CI, 1.17-1.20) following 2 visits, and 1.22 (95% CI, 1.20-1.23) after at least 3 maternal visits. A low-acuity maternal prepregnancy ED visit was associated with an adjusted odds ratio (aOR) of 5.52 (95% CI, 5.16-5.90) for a low-acuity infant ED visit, which was numerically higher than the pairing of a high-acuity ED use between mother and infant (aOR, 1.43, 95% CI, 1.38-1.49). In this cohort study of singleton livebirths, prepregnancy maternal ED use was associated with a higher rate of ED use by the infant in the first year of life, especially for low-acuity ED use. This study's results may suggest a useful trigger for health system interventions aimed at reducing some ED use in infancy.

The interagency care team: A new model to integrate social and medical care for older adults in primary care.

To integrate management of social drivers of health with complex clinical needs of older adults, we connected patients aged 60 and above from primary care practices with a nurse practitioner (NP) led Interagency Care Team (ICT) of geriatrics providers and community partners via electronic consult. The NP conducted a geriatric assessment via telephone, then the team met to determine recommendations. Thirteen primary care practices referred 123 patients (median age=76) who had high rates of emergency department use and hospitalization (28.9% and 17.4% respectively). Issues commonly identified included medication management (84%), personal safety (72%), disease management (69%), food insecurity (63%), and cognitive decline (53%). Referring providers expressed heightened awareness of older adults' social needs and high satisfaction with the program. The ICT is a scalable model of care that connects older adults with complex care needs to geriatrics expertise and community services through partnerships with primary care providers.

Food Apartheid and Food Insecurity

A Food desert usually occurs in a low-income or minority community with limited access to low-cost fresh and healthy food options. This is due mainly to a lack of grocery stores, farmers’ markets, and healthy food providers, resulting in food insecurity. Household food insecurity was related to significantly worse general health, some acute and chronic health problems, and worse health care access, including forgone care and heightened emergency department use, for children. Compared to rates had they not been food insecure, children in food-insecure households had higher rates of lifetime asthma diagnosis and depressive symptoms, which were 19.1% and 27.9% higher, rates of forgone medical care that were 179.8% higher, and rates of emergency department use that were 25.9% higher. This paper explores food deserts, food insecurity, and occurrences of food apartheid and recommends potential solutions.

Trends and Variations in Emergency Department Use Associated With Diabetes in the US by Sociodemographic Factors, 2008-2017

Little is known about emergency department (ED) use among people with diabetes and whether the pattern of ED use varies across geographic areas and population subgroups. To estimate recent national- and state-level trends in diabetes-related ED use overall and by race and ethnicity, rural or urban location, and insurance status. This cross-sectional study of adults visiting the ED with a diabetes-related diagnosis used serial data from the Nationwide Emergency Department Sample, a nationally representative database, and discharge records from 11 state emergency department databases for 2008, 2011, 2014, and 2016 to 2017. Data were analyzed from March 16 to November 9, 2020. Reported race and ethnicity, rural or urban location, and insurance status. Data were stratified to generate state-specific estimates. Rates of ED use for all-cause visits among adults with diabetes (all-cause diabetes visits) and visits with primary diagnoses of diabetes-specific complications. A larger portion of all-cause diabetes ED visits (n = 32 433 015) were by female (56.8%) and middle-aged (mean [SD] age, 58.4 [16.3] years) adults with diabetes. Nationally, all-cause diabetes ED visits per 10 000 adults increased 55.6% (95% CI, 50.6%-60.6%), from 257.6 (95% CI, 249.9-265.3) visits in 2008 to 400.8 (95% CI, 387.6-414.0) visits in 2017. All-cause diabetes ED visits increased more for urban (58.3%; 95% CI, 52.5%-64.1%) and uninsured subgroups (75.3% [95% CI, 59.8%-90.8%]) than for their counterparts. Diabetes-specific ED visits (weighted number of 1 911 795) nationally increased slightly among all subgroups. State-specific ED use rates show wide state-to-state variations in ED use by race and ethnicity, rural or urban location, and insurance. On average across states, diabetes-specific ED use among Black patients was approximately 3 times (rate ratio, 3.09 [95% CI, 2.91-3.30]) greater than among non-Hispanic White patients, and among Hispanic patients, it was 29% greater (rate ratio, 1.29 [95% CI, 1.19-1.40]) than among non-Hispanic White patients. The mean rate of ED use among rural patients was 34% greater (rate ratio, 1.34 [95% CI, 1.26-1.44]) than among urban patients. The mean rates of ED use among patients with Medicaid (rate ratio, 6.65 [95% CI, 6.49-6.82]) and Medicare (rate ratio, 4.37 [95% CI, 4.23-4.51]) were greater than among privately insured adults. This study suggests that disparities in diabetes-related ED use associated with race and ethnicity, rural or urban location, and insurance status were persistent from 2008 to 2017 within and across states, as well as nationally. Further geographic and demographic-specific analyses are needed to understand the sources of inequity.

Assessing Health Care Use Trajectories After the Onset of Functional Disability: Application of a Group-Based Trajectory Model.

While older adults with activity limitations have high levels of health care use, we do not know how this varies over time. We aimed to assess trajectories of Emergency Department (ED) use and hospitalization after the onset of receipt of help with self-care or mobility. We used the 2011-2017 National Health Aging Trends Study (NHATS) linked to Medicare claims to identify a cohort of older adults who began to receive help with self-care or mobility in the past year. Primary outcome was the quarterly rates of ED use and/or hospitalization over the 24 months following the onset of receiving help. We fit a Group-Based Trajectory Model to identify the trajectories of ED use or hospitalization and assessed the association of characteristics preceding and concurrent to the onset of help with trajectory group membership. Among 1,687 NHATS respondents newly receiving help with self-care/mobility, health care use escalated and then immediately fell. We found distinct trajectories of ED use and hospitalization: delayed rise (13.5%), falling (26.2%), and persistent (60.4%). Trajectory group membership was predicted by clinical, economic, and regional characteristics; and the individuals in each group differed in terms of concurrent new illnesses and degree of disability. While activity limitations are a strong predictor of health care use among older adults, trajectories of health care use are heterogeneous. Along with clinical characteristics, potentially modifiable household and regional factors shaped health care trajectories, indicating that addressing these factors could potentially shift health care use patterns.

Identifying patterns of health care utilisation among physical elder abuse victims using Medicare data and legally adjudicated cases: protocol for case–control study using data linkage and machine learning

IntroductionPhysical elder abuse is common and has serious health consequences but is under-recognised and under-reported. As assessment by healthcare providers may represent the only contact outside family for many older...

Emergency Department Use Among Assisted Living Residents After Hurricane Irma

ObjectivesNursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida. DesignRetrospective cohort study. Setting and ParticipantsSamples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities. MeasuresThe number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017. ResultsAdjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016. Conclusions and ImplicationsIncreased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review.

Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. Housing stability, physical and mental health outcomes, and health care utilization. Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter?

ObjectivesMedicaid nursing home (NH) reimbursement rates and bed-hold policies have been shown to be associated with hospitalization of urban NH residents, but their relationships with emergency department (ED) visits, especially in rural NHs, remain unknown. This study explores the relationships of Medicaid NH policies with three NH quarterly risk-adjusted rates of ED use for long-stay residents and evaluates whether the associations differed by NHs' geographical locations. DesignLongitudinal study of Medicaid policies and NH risk-adjusted rates over 3 quarters (2011 Q3, 2012 Q3, and 2013 Q3), using Generalized Estimating Equation (GEE) models. Setting and Participants14,514 unique NHs. MeasuresQuarterly risk-adjusted rates of any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) were calculated from national Medicare claims and NH Minimum Data Set 3.0. Medicaid policies were consolidated from several publicly available sources. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and the Area Health Resources File. ResultsIn 2012, states reimbursed NHs, on average, $162.60 per resident-day, and 36 states employed bed-hold policies. Although a $10 increase in reimbursement rates was associated with statistically significantly lower rates of any ED, outpatient ED, and PAED in both urban and micropolitan NHs (−0.79%, −1.09%, and −1.02% for urban NHs; −1.29%, −1.90%, and −3.22% for micropolitan NHs, respectively), it was not associated with any ED measure in rural NHs. Medicaid bed-hold polices were associated with about 9% to 12% lower rates of all types of ED visits in urban NHs, but were not related to any of the ED measures in micropolitan and rural NHs. Conclusions and ImplicationsAssociations of Medicaid NH policies with ED utilization are weaker in rural NHs than urban NHs. Yet, the financial viability of increasing Medicaid reimbursement to reduce the ED use may not be cost-effective.

1206-P: Preventable and Other Emergency Department Use in Adults with and without Diabetes, 2009-2017

There are limited data comparing trends in overall and potentially preventable emergency department (ED) visits between adults with and without diabetes. We analyzed data from the Medical Expenditure Panel Survey and pooled cohorts for years 2009-12 and 2014-17. We identified adults with diabetes by self-report, diabetes-specific ICD-codes, or prescriptions for antidiabetic agents. Potentially preventable visits were identified using ICD-codes specific to Ambulatory Care Sensitive Conditions (ACSCs), a list of conditions that can be prevented by primary care interventions (e.g., Urinary Tract Infection, Heart Failure, and Bacterial Pneumonia). We used event-level data to estimate weighted age- and sex-adjusted rates of average annual ED visits per 1000 persons and calculated standardized rate ratios by years and diabetes status. Compared to 2009-12, rates of ED use were higher among adults without diabetes in 2014-17 compared to 2009-12 (RR: 1.11). Compared to 2009-12, adults with diabetes in 2014-17 had no significant change in rates of ED use. In 2014-2017, compared to adults without diabetes, those with diabetes had twice the rate of ED service use (RR: 2.07) and had a 47% higher rate of preventable visits (RR: 1.47). Further research is required to understand factors that might be associated with the higher rates of ED use among people with diabetes. Disclosure T.S. Uppal: None. J. Haw: None. M.K. Shah: None. S. Turbow: Research Support; Self; Gilead Sciences, Inc. K. Narayan: None. M.K. Ali: Research Support; Self; Merck & Co., Inc.

4269 Frequent emergency department use among homeless individuals seen in emergent care: High risks of opioid-related diagnoses and adverse health services utilization outcomes

OBJECTIVES/GOALS: Using multi-state discharge data, to identify predictors of frequent emergency department (ED) use among the homeless patients seen in emergent care, and to compare frequent versus less frequent homeless ED users for their risk of serious health services utilization outcomes. METHODS/STUDY POPULATION: Based on the State Emergency Department Database and the State Inpatient Database, homeless individuals (n = 88,541) who made at least one ED visit in four states (Florida, Maryland, Massachusetts, and New York) in 2014. In this retrospective cross-sectional analysis, patient-level demographic and clinical factors were assessed as predictors for increased ED use. Risks of opioid overdose, opioid-related hospital admission/ED visit, in-hospital mortality, mechanical ventilation, and number of hospitalizations were compared between individuals with 4 or more vs. 2-3 vs. 1 ED visit(s), adjusting for potential confounders including hospital fixed effects (allowing for within hospital comparisons). RESULTS/ANTICIPATED RESULTS: Higher rates of ED use were associated with Medicare coverage <65; primary diagnosis of alcohol abuse, asthma, or abdominal pain; and co-morbidity of alcohol abuse, psychoses, or chronic pulmonary disease. Individuals with ≥4 visits had significantly higher adjusted risk of opioid overdose (3.7% vs. 1.2% vs. 1.0%), opioid-related hospitalizations/ED visits (17.9% vs. 8.5% vs. 6.6%), mechanical ventilation (9.8% vs. 7.0% vs. 4.7%), and greater # of hospitalizations (3.2 vs. 1.3 vs. 0.8) compared to individuals with 2-3 or 1 ED visit. Individuals with ≥4 and 2-3 ED visits had similar but increased risks of in-hospital mortality compared to individuals with 1 ED visit (2.8% vs. 2.8% vs. 2.3%). DISCUSSION/SIGNIFICANCE OF IMPACT: Homeless patients who were high ED users were more likely to be hospitalized and have other adverse outcomes. These findings encourage targeted interventions (i.e. housing) for the high-utilizer homeless population to reduce the burden of serious outcomes and costs for the patient and society.

1566-P: Association of Demographic Factors with Emergency Department Use among Adults with Diabetes, 2009-2017

There are limited data which examine the current trends in emergency department (ED) use among adults with all-type diabetes by demographic characteristics. We analyzed data from the nationally representative Medical Expenditure Panel Survey (MEPS), which uses a rotating panel design—a new cohort is initiated annually, and health care use is recorded over the course of 2 years. We pooled panels, each with 2-year follow-up into years 2009-2012 and 2014-2017 to improve precision. We identified adults with diabetes by self-report, presence of diabetes-specific ICD-codes, or prescriptions of antidiabetic agents and used all-cause event-level ED data to estimate weighted counts and age-adjusted rates of average annual ED visits per 1000 persons with diabetes. We then compared rates of ED use between the two time periods by calculating absolute and percent change. Increases in use were greatest among the groups: 65-74 yrs (38.1%), 75+ yrs (28.6%), West (27.3%), Midwest (16.5 %), Female (19.4%), and White (15.9%). The share of visits by the uninsured dropped (10.1% to 5.3%), while share of visits increased (29% to 36.3%) for those covered by Medicaid (data not shown). Further analysis will be conducted to analyze the trend over time from earlier time periods (2004-2007), understand the type of event (nondiabetes vs. diabetes-related) and stratify by potentially preventable visit and insurance type. Disclosure T.S. Uppal: None. G. Fernandes: Employee; Spouse/Partner; Janssen Pharmaceuticals, Inc. Employee; Self; Merck Sharp & Dohme Corp. J. Haw: None. M.K. Shah: None. S. Turbow: Research Support; Self; Gilead Sciences, Inc. S. Rajpathak: Employee; Self; Menarini Group. K. Narayan: None. M.K. Ali: Research Support; Self; Merck & Co., Inc.

Assessing National Trends and Disparities in Ambulatory, Emergency Department, and Inpatient Visits for Inflammatory Bowel Disease in the United States (2005–2016)

Patients with inflammatory bowel diseases (IBDs) require repeated health care encounters, although the focus of care differs when patients are seen in ambulatory, emergency department (ED), or inpatient settings. We examined contemporary trends and disparities in IBD-related health care visits. We used data from the National Ambulatory Medical Care Survey, the Nationwide Emergency Department Sample, and the National Inpatient Sample to estimate the total number of annual IBD-related visits from 2005 through 2016. We performed logistic regression analyses to test temporal linear trends. Slope and differences in distributions of patient demographics were compared across time and treatment settings. From 2005 through 2016, approximately 2.2 million IBD-related ambulatory visits (95 CI, 1.9-2.5) occurred annually on average, increasing by 70.3% from the time period of 2005 to 2007 through the time period of 2008 to 2010, and decreasing by 19.8% from the time period of 2011 to 2013 through the time period of 2014 to 2016. An average of 115,934 IBD-related ED visits(95% CI, 113,758-118,111) and 89,111 IBD-related hospital discharges (95% CI, 87,416-90,807) occurred annually. Significant increases in the rate of IBD-related ED visits (3.2 visits/10,000 encounters; P < .0001) and hospital discharges (6.0 discharges/10,000 encounters; P < .0001) were observed from 2005 through 2016. The proportion of patients paying with private insurance decreased from 2005 through 2016, among all care settings. A greater proportion of young patients, patients with Crohn's disease, non-white patients, and patients with Medicare or Medicaid used hospital-based vs ambulatory services. In an analysis of data from 3 large databases, we found that although IBD-related ambulatory visits stabilized to decreased from 2005 through 2016, rates of ED use and admission to the hospital have continued to increase with changes in patient demographics, over time and among care settings.