National study of health insurance type and reasons for emergency department use

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury

Background

Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability.

Hypothesis

Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables.

Results

While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049).

Conclusion

In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.

A mobile integrated health program for the management of undifferentiated acute complaints in older adults is safe and feasible

BACKGROUND

Poor care access and lack of proper triage of medical complaints leads to inappropriate use of acute care resources. Mobile integrated health (MIH) programs may offer a solution by providing adaptable on-demand care. There is little information describing programs that manage undifferentiated complaints in the community. The objective of this study was to assess the safety and feasibility of an MIH program that responds to the community to manage medical complaints in older adults.

METHODS

This was a prospective observational study examining a pilot MIH program. Seven ambulatory clinics and their affiliated patients aged 65 and older were oriented to the program and invited to use its services. Visit and follow-up data for all patients who underwent an MIH visit were abstracted, along with 30-day follow-up information. All demographic data and outcomes were reported descriptively.

RESULTS

In 21 months, 153 MIH visits were completed, involving 91 patients (mean age 81 years, 60.4% female). The most common chief complaints were generalized weakness (28.8%) and shortness of breath (18.9%). Electrocardiogram (57.5%) and point-of-care bloodwork (34.6%) were the most common diagnostic tests performed. Sixteen visits (10.4%) were followed by an emergency department (ED) visit within 72 h. In 11 encounters, the patient was referred to the ED; in five cases, the ED visit was unforeseen. Fifteen patients (9.8%) were admitted to the hospital after an MIH visit. There were two deaths within 30 days following an index visit.

CONCLUSIONS

An MIH program designed to address the acute complaints of community-dwelling older adults was feasible and safe, with low rates of unforeseen emergency services utilizations. MIH programs have valuable diagnostic and therapeutic capabilities and may serve to help triage the acute medical needs of patients. Further study is required to validate the efficacy and cost-effectiveness of MIH programs.

Medicaid Coverage and Emergency Department Utilization in Southeastern Pennsylvania

Overutilization of the emergency department (ED) is a significant problem in the United States (US), characterized mainly by patients with non-emergent conditions seeking care in a setting designed specifically for acute care. This has significantly increased healthcare costs in the US, a country with one of the most expensive healthcare systems in the world. ED overutilization was also found to be high among people with Medicaid coverage, especially since the Affordable Care Act was enacted with an expansion in Medicaid coverage. Using the 2018 South Eastern Pennsylvania (SEPA) Household Health Survey, we identified a significant bivariate relationship between emergency department visits and the following predictor variables: sex, race, education, employment status, 150% poverty level, and Medicaid recipient. Using a multivariable logistic regression model, Medicaid recipients had higher odds of presenting to the ED than non-Medicaid recipients [odds ratio (OR): 2.863, 95% confidence interval (CI): 2.164, 3.788]. Black people (OR: 1.647, 95% CI: 1.411, 1.923) and Native Americans (OR: 2.985, 95% CI: 1.536, 5.800) had higher odds than Whites. Respondents without a high school diploma had higher odds than college graduates (OR: 1.647, 95% CI: 1.96, 2.273). Respondents below the 150% poverty line had higher odds than those at or above the 150% poverty level (OR: 1.651, 95% CI: 1.386, 1.968). Unemployed respondents had higher odds than full-time employed respondents (OR: 1.703, 95% CI: 1.488, 1.953) or part-time (OR: 1.259, 95% CI: 1.036, 1.529). No difference was observed between the sexes. Addressing ED overutilization should take a multi-faceted approach with the ultimate goal of improving access to primary care.

Understanding Characteristics and Predictors of Admission From the Emergency Department for Patients With Intellectual Disability

The goal of this investigation is to compare rates of admission from the emergency department (ED) and the characteristics of patients with intellectual disability (ID) who get admitted from the ED. This was a retrospective study using data from the United States' Nationwide Emergency Data Sample (NEDS) to investigate the associations between the diagnosis of ID and admission to the hospital in patients ≥ 18 years during the years 2016-2017. Adults with ID were almost four times as likely to be admitted to the hospital from the ED as patients who were not identified as having ID. Identifying the major contributors to increased admission for patients with ID may help improve their care.

Comparing International Experiences With Electronic Health Records Among Emergency Medicine Physicians in the United States and Norway: Semistructured Interview Study

Background

The variability in physicians’ attitudes regarding electronic health records (EHRs) is widely recognized. Both human and technological factors contribute to user satisfaction. This exploratory study considers these variables by comparing emergency medicine physician experiences with EHRs in the United States and Norway.

Objective

This study is unique as it aims to compare individual experiences with EHRs. It creates an opportunity to expand perspective, challenge the unknown, and explore how this technology affects clinicians globally. Research often highlights the challenge that health information technology has created for users: Are the negative consequences of this technology shared among countries? Does it affect medical practice? What determines user satisfaction? Can this be measured internationally? Do specific factors account for similarities or differences? This study begins by investigating these questions by comparing cohort experiences. Fundamental differences between nations will also be addressed.

Methods

We used semistructured, participant-driven, in-depth interviews (N=12) for data collection in conjunction with ethnographic observations. The conversations were recorded and transcribed. Texts were then analyzed using NVivo software (QSR International) to develop codes for direct comparison among countries. Comprehensive understanding of the data required triangulation, specifically using thematic and interpretive phenomenological analysis. Narrative analysis ensured appropriate context of the NVivo (QSR International) query results.

Results

Each interview resulted in mixed discussions regarding the benefits and disadvantages of EHRs. All the physicians recognized health care’s dependence on this technology. In Norway, physicians perceived more benefits compared with those based in the United States. Americans reported fewer benefits and disproportionally high disadvantages. Both cohorts believed that EHRs have increased user workload. However, this was mentioned 2.6 times more frequently by Americans (United States [n=40] vs Norway [n=15]). Financial influences regarding health information technology use were of great concern for American physicians but rarely mentioned among Norwegian physicians (United States [n=37] vs Norway [n=6]). Technology dysfunctions were the most common complaint from Norwegian physicians. Participants from each country noted increased frustration among older colleagues.

Conclusions

Despite differences spanning geographical, organizational, and cultural boundaries, much is to be learned by comparing individual experiences. Both cohorts experienced EHR-related frustrations, although etiology differed. The overall number of complaints was significantly higher among American physicians. This study augments the idea that policy, regulation, and administration have compelling influence on user experience. Global EHR optimization requires additional investigation, and these results help to establish a foundation for future research.

Increased Total Cost and Lack of Diagnostic Utility for Emergency Department Visits After ACL Injury

Background:

Patients are commonly evaluated at the emergency department (ED) with acute anterior cruciate ligament (ACL) tears, but providers without orthopaedics training may struggle to correctly diagnose these injuries.

Hypothesis:

It was hypothesized that few patients would be diagnosed with an ACL tear while in the ED and that these patients would be of lower socioeconomic status and more likely to have public insurance.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

The 2017 State Ambulatory Surgery and Services Database (SASD) and State Emergency Department Database (SEDD) from the state of Florida were utilized in this study. Cases with Current Procedural Terminology code 29888 (arthroscopically aided ACL reconstruction [ACLR]) were selected from the SASD, and data from the SEDD were matched to patients who had an ED visit for a knee injury within 120 days before ACLR. Chi-square analysis was used to test for differences in patient and surgical variables between the ED visit and nonvisit patient groups. A generalized linear model was created to model the effect of ED visit on total cost for an ACL injury.

Results:

While controlling for differences in patient characteristics and concomitant procedure usage, a visit to the ED added $4587 in total cost (P < .001). The ED visit cohort contained a greater proportion of patients with Medicaid (20.2% vs 9.1%), patients who were Black (18.4% vs 10.3%), and patients in the lowest income quartile (34.4% vs 25.0%) (P < .001 for all). In the ED visit cohort, 14.4% of patients received an allograft versus 10.1% in the non-ED visit cohort (P = .001) despite having a similar mean age. An ACL sprain was diagnosed in only 29 of the 645 (4.5%) patients who visited the ED.

Conclusion:

Utilizing the ED for care after an ACL injury was expensive, averaging a $4587 increase in total cost associated with ACLR. However, patients rarely left with a definitive diagnosis, with only 4.5% of patients who underwent ACLR being correctly diagnosed with an ACL tear in the ED. This additional cost was levied disproportionately on patients of low socioeconomic status and patients with Medicaid.

Availability of Adult Vaccination Services by Provider Type and Setting

INTRODUCTION

Knowledge regarding the benefits for adult vaccination services under Medicaid's fee-for-service arrangement is dated; little is known regarding the availability of vaccination services for adult Medicaid beneficiaries in MCO arrangements. This study evaluates the availability of provider reimbursement benefits for adult vaccination services under fee-for-service and MCO arrangements for different types of healthcare providers and settings.

METHODS

A total of 43 Medicaid directors across the 50 U.S. states and the District of Columbia participated in a semistructured survey conducted from June 2018 to June 2019 (43/51). The frequency of Medicaid fee-for-service and MCO arrangements reporting reimbursement for adult vaccination services by various provider types and settings were assessed in 2019. Elements of vaccination services examined in this study were vaccine purchase, vaccine administration, and vaccination-related counseling.

RESULTS

Under fee-for-service, 41 Medicaid programs reimburse primary care providers for adult vaccine purchase (41/43); fewer programs reimburse vaccine administration and vaccination-related counseling (33/43 and 30/43, respectively). Similar results were observed for obstetricians-gynecologists, nurse practitioners, and pharmacies. Although 24 fee-for-service (24/43) and 23 MCO (23/34) arrangements cover adult vaccination services in most settings, long-term care facilities have the lowest reported reimbursement eligibility.

CONCLUSIONS

In most jurisdictions, vaccination services for adult Medicaid beneficiaries are available for a variety of healthcare provider types and settings under both fee-for-service and MCO arrangements. However, because provider reimbursement benefits remain inconsistent for adult vaccination counseling services and within long-term care facilities, access to adult vaccination services may be reduced for Medicaid beneficiaries who depend on these resources.

Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

BACKGROUND

The health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.

OBJECTIVE

This study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.

DESIGN

An observational study was conducted using national VA administrative data from 2016 to 2019.

PARTICIPANTS

Data on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.

MAIN MEASURES

Homelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).

KEY RESULTS

The most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22-24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans.

CONCLUSIONS

These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.

High-deductible health plans and low-value imaging in the emergency department

OBJECTIVE

To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging.

DATA SOURCES

Claims data of a large national insurer between 2003 and 2014.

STUDY DESIGN

Difference-in-differences analysis with matched control groups.

DATA COLLECTION/EXTRACTION METHODS

The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation.

PRINCIPAL FINDINGS

After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging.

CONCLUSION

Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.

Trends and Related Factors of Cannabis-Associated Emergency Department Visits in the United States: 2006-2014

OBJECTIVES

To examine national trends and contributing factors of cannabis-associated emergency department visits in the United States.

METHODS

This pooled serial cross-sectional study used a hierarchical multivariable analysis on emergency department visit adjusting for year, patient and hospital characteristics. We analyzed 2006 to 2014 National Emergency Department Sample data that identified cannabis-associated emergency department visits among patients aged 12 years or older (n = 265,128).

RESULTS

Cannabis-associated emergency department visits per 100,000 emergency department discharges increased monotonically (annually by 7%). As compared with privately insured patients, Medicare, and Medicaid, uninsured patients were over 40% more likely to visit emergency department. The age group 12 to 17 had the highest risk of emergency department visits and the risk monotonically declined as the age increased. Hospitals in the South region showed the highest cannabis-associated emergency department utilization, yet trends of cannabis-associated emergency department visits increased in the West region from 15.4% to 26% over time.

CONCLUSIONS

Cannabis-associated emergency department visits increase monotonically over time. Although vulnerable persons were identified, additional policy or regional factors should explore risks of emergency department visits associated with cannabis use.

Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community

Background

A rapidly ageing population with increasing prevalence of chronic disease presents policymakers the urgent task of tailoring healthcare services to optimally meet changing needs. While healthcare needs-based segmentation is a promising approach to efficiently assessing and responding to healthcare needs at the population level, it is not clear how available schemes perform in the context of community-based surveys administered by non-medically trained personnel. The aim of this prospective cohort, community setting study is to evaluate 4 segmentation schemes in terms of practicality and predictive validity for future health outcomes and service utilization.

Methods

A cohort was identified from a cross-sectional health and social characteristics survey of Singapore public rental housing residents aged 60 years and above. Baseline survey data was used to assign individuals into segments as defined by 4 predefined population segmentation schemes developed in Singapore, Delaware, Lombardy and North-West London. From electronic data records, mortality, hospital admissions, emergency department visits, and specialist outpatient clinic visits were assessed for 180 days after baseline segment assignment and compared to segment membership for each segmentation scheme.

Results

Of 1324 residents contacted, 928 agreed to participate in the survey (70% response). All subjects could be assigned an exclusive segment for each segmentation scheme. Individuals in more severe segments tended to have lower quality of life as assessed by the EQ-5D Index for health utility. All population segmentation schemes were observed to exhibit an ability to differentiate different levels of mortality and healthcare utilization.

Conclusions

It is practical to assign individuals to healthcare needs-based population segments through community surveys by non-medically trained personnel. The resulting segments for all 4 schemes evaluated in this way have an ability to predict health outcomes and utilization over the medium term (180 days), with significant overlap for some segments. Healthcare needs-based segmentation schemes which are designed to guide action hold particular promise for promoting efficient allocation of services to meet the needs of salient population groups. Further evaluation is needed to determine if these schemes also predict responsiveness to interventions to meet needs implied by segment membership.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BACKGROUND

Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.

METHOD

The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.

RESULTS

Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.

CONCLUSION

Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.

Primary Care Provider Encounter Cadence and HbA1c Control in Older Patients With Diabetes

INTRODUCTION

Primary care provider encounters are associated with health and well-being; however, limited evidence guides optimal primary care provider rate of visit, referred to as encounter cadence. This study measures associations between primary care provider encounter cadence and diabetes outcomes among individuals newly diagnosed with type 2 diabetes mellitus.

METHODS

In this retrospective cohort study, 7,106 people enrolled in Medicare Advantage and newly diagnosed with type 2 diabetes mellitus between July 1, 2012 and June 30, 2013 were identified and followed for 36 months. Two methods measured primary care provider encounter cadence: total primary care provider encounters (frequency) and quarters with primary care provider encounter (regularity). Logistic regression measured relationships between primary care provider encounter cadence and non-insulin diabetes medication adherence, HbA1c control, emergency department visits, and inpatient admissions. Non-insulin diabetes medication adherence was defined according to the National Committee for Quality Assurance, Healthcare Effectiveness Data and Information Set specifications and measured using healthcare claims data. Post-hoc models examined adherence and diabetes control among those nonadherent (n=5,212) and with noncontrolled HbA1c (n=326) during the encounter/cadence period. Data were extracted and analyzed in 2017.

RESULTS

Adjusted models indicated that both frequency (AOR=1.08, 95% CI=1.06, 1.10) and regularity (AOR=1.18, 95% CI=1.13, 1.22) of primary care provider encounters were associated with increased odds of adherence. Post-hoc analyses indicated that more frequent (AOR=1.12, 95% CI=1.10, 1.15) and regular (AOR=1.27, 95% CI=1.22, 1.33) primary care provider encounters were associated significantly with adherence and were associated directionally with HbA1c control.

CONCLUSIONS

More frequent and regular primary care provider encounters are associated with an increased likelihood of non-insulin diabetes medication adherence. These findings contribute to data needed to establish evidence-based guidelines for primary care provider encounter cadence for those newly diagnosed with type 2 diabetes mellitus.

The Impact of Medicaid Managed Care on Health Service Utilization Among Adults With Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) are frequent users of health services. We examined how their service utilization of emergency department (ED), inpatient hospitalization, and primary care physicians changed as they transitioned from fee-for-service to Medicaid managed care (MMC). Our results showed that MMC reduced the utilization of all of these services. A substantial decrease in ED visits was associated with the reduction in visits due to mental/behavioral health conditions and conditions that could be nonemergent and manageable with the community-based health services. These findings suggest that health service utilization of people with IDD is related not only to their health needs, but also to the delivery model that provides their health services.

General practitioner consultation after a visit to the emergency department: an observational study

BACKGROUND

Some studies have demonstrated an association between poor continuity of care, high likelihood of 'inappropriate' use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit.

OBJECTIVE

Identify the determinants of a visit to the general practitioner (GP) after an ED visit.Methods.

DESIGN

Observational study (single-centre cohort).

SETTING

One emergency department in Paris, France.

SUBJECTS

All adult patients who presented at the ED and were discharged.

MAIN OUTCOME MEASURE

We collected data by the use of a standardized questionnaire, patients' medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation.

RESULTS

We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74).

CONCLUSION

Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints.

Telehealth Impact on Primary Care Related Ambulance Transports

Introduction: Telehealth has been used nominally for trauma, neurological, and cardiovascular incidents in prehospital emergency medical services (EMS). Yet, much less is known about the use of telehealth for low-acuity primary care. We examine the development of one telehealth program and its impact on unnecessary ambulance transports. Objective: The objective of this study is to describe the development and impact of a large-scale telehealth program on ambulance transports. Methods: We describe the patient characteristics and results from a cohort of patients in Houston, Texas who received a prehospital telehealth consultation from an emergency medicine physician. Inclusion criteria were adults and pediatric patients with complaints considered to be non-urgent, primary care related. Data were analyzed for 36 months, from January 2015 through December 2017. Our primary dependent variable was the percentage of patients transported by ambulance. We used descriptive statistics to describe patient demographics, chi-square to examine differences between groups, and logistic regression to explore the effects with multivariate controls including age, gender, race, and chief complaint. Results: A total of 15,067 patients were enrolled (53% female; average age 44 years ± 19 years) over the three-year period. The 3 primary chief complaints were based on abdominal pains (13% of cases), nausea/vomiting/diarrhea (NVD) (9.4%), and back pain (9.3%). Ambulance transports represented 11.2% of all transports in the program, while alternative taxi transportation was used in 75.6%, and the remainder were self- or no-transports. Taxi transportation to an alternate, affiliated clinic (versus ED) was utilized in 5% of incidents. After multivariate controls, older age patients presenting with low-risk, non-acute chest pain, shortness of breath, and dizziness were much more likely to use ambulance transport. Race and gender were not significant predictors of ambulance transport. Conclusions: We found telehealth offers a technology strategy to address potentially unnecessary ambulance transports. Based on prior cost-effectiveness analyses, the reduction of unnecessary ambulance transports translates to an overall reduction in EMS agency costs. Telehealth programs offer a viable solution to support alternate destination and alternate transport programs.

Association of office-based provider visits with emergency department utilization among publicly insured stroke survivors

OBJECTIVE

To evaluate the association between visits to office-based providers and Emergency Department (ED) utilization among stroke survivors.

METHODS

We analyzed 12-years of data representing a weighted sample of 3,317,794 publicly insured US adults aged ≥18 years with stroke, using the Medical Expenditure Panel Survey Household Component (MEPS-HC), 2003-2014 dataset. We used a negative binomial regression model that accounts for dispersion to estimate the association between office-based and ED visits controlling for covariates. We used a multivariate logistic regression model to identify independent predictors of ED visits.

RESULTS

Annual mean (SD) ED visits and office based visits for publicly insured stroke survivors were 0.60 (1.10) and 12.2 (19.9) respectively. Each unit increase in office based visits was associated with a 1% increase in ED visit (p = 0.008). Being unmarried (adjusted OR = 1.26; 95% CI: 1.015-1.564) and having several comorbidities (adjusted OR = 1.93; 95% CI: 1.553-2.412) were associated with a higher likelihood of at least one ED visit. The odds for an ED visit for individuals aged 45-64, those aged 65 years and above, and those with a college or higher level of education were respectively 34% (OR = 0.66; 95% CI: 0.454-0.965), 52% (OR = 0.48; 95% CI: 0.330-0.701), and 36% (OR = 0.64; 95% CI: 0.497-0.834) lower than their counterparts.

CONCLUSIONS

Contrary to our expectations, there was a direct relationship between ED visits and office base visits among U.S. stroke survivors. This finding may reflect the difficulties associated with managing stroke survivors with multiple co-morbidities or complex psycho-socio-economic issues.

Insurance Type and Access to Health Care Providers and Appointments Under the Affordable Care Act

BACKGROUND

Millions of adults have gained insurance through the Affordable Care Act (ACA). However, disparities in access to care persist.

OBJECTIVE

This study examined differences in access to primary and specialty care among patients insured by private individual market insurance plans (both on-exchange and off-exchange) and Medicaid compared with those with employer-sponsored insurance.

RESEARCH DESIGN

Using data from the 2014 and 2015 California Health Interview Survey, logistic regression analyses were used to calculate the odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor's appointment in a timely manner, with insurance type serving as the independent variable. Interaction terms examined if the expiration of the ACA's optional Medicaid primary care fee increase in 2014 modified any of these associations.

RESULTS

Findings showed poorer access to providers among those insured through Medicaid and the individual market (whether purchased through the state's health insurance exchange or off-exchange) relative to employer-based insurance. Poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. In addition, findings showed that reduction of Medicaid fees coincided with reduced ability to see primary care providers. However, a similar trend was seen among those with employer-based coverage, which suggests that this change may not be attributable to reductions in Medicaid fees.

CONCLUSION

Despite ACA-related gains in insurance coverage, those with on-exchange and off-exchange individual private insurance plans and Medicaid encounter more barriers to care than those with employer-based insurance.

Substance Use, Homelessness, Mental Illness and Medicaid Coverage: A Set-up for High Emergency Department Utilization

Introduction

Frequent users of emergency departments (ED) account for 21–28% of all ED visits nationwide. The objective of our study was to identify characteristics unique to patients with psychiatric illness who are frequent ED users for mental health care. Understanding unique features of this population could lead to better care and lower healthcare costs.

Methods

This retrospective analysis of adult ED visits for mental healthcare from all acute care hospitals in California from 2009–2014 used patient-level data from California’s Office of Statewide Health Planning and Development. We calculated patient demographic and visit characteristics for patients with a primary diagnosis of a mental health disorder as a percentage of total adult ED visits. Frequent ED users were defined as patients with more than four visits in a 12-month period. We calculated adjusted rate ratios (aRR) to assess the association between classification as an ED frequent user and patient age, sex, payer, homelessness, and substance use disorder.

Results

In the study period, 846,867 ED visits for mental healthcare occurred including 238,892 (28.2%) visits by frequent users. Patients with a primary mental health diagnosis and a co-occurring substance use diagnosis in the prior 12 months (77% vs. 37%, aRR [4.02], 95% confidence interval [CI] [3.92–4.12]), homelessness (2.9% vs 1.1%, odds ratio [1.35], 95% [CI] [1.27–1.43]) were more likely to be frequent users. Those covered by Medicare (aRR [3.37], 95% CI [3.20–3.55]) or the state’s Medicaid program Medi-Cal (aRR [3.10], 95% CI [2.94–3.25]) were also more likely to be frequent users compared with those with private insurance coverage.

Conclusion

Patients with substance use disorders, homelessness and public healthcare coverage are more likely to be frequent users of EDs for mental illness. Substance use and housing needs are important factors to address in this population.

Factors Associated With Emergency Department Use by Patients With and Without Mental Health Diagnoses

IMPORTANCE

An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use.

OBJECTIVE

To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California's Office of Statewide Health Planning and Development were analyzed.

MAIN OUTCOMES AND MEASURES

Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis.

RESULTS

Among the 3 446 338 individuals in the study (accounting for 7 678 706 ED visits), 44.6% (1 537 067) were male; 31.6% (1 089 043) were between the ages of 18 and 30 years, 40.3% (1 338 874) were between the ages of 31 and 50 years, and 28.1% (968 421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1 002 884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use.

CONCLUSIONS AND RELEVANCE

Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.

Non-urgent use of emergency departments: populations most likely to overestimate illness severity

Patients' overestimation of their illness severity appears to contribute to the national epidemic of emergency department (ED) overcrowding. This study aims to elucidate which patient populations are more likely to have a higher estimation of illness severity (EIS). The investigator surveyed demographic factors of all non-urgent patients at an academic ED. The patients and physicians were asked to estimate the patients' illness severity using a 1-10 scale with anchors. The difference of these values was taken and compared across patient demographic subgroups using a 2-sample t-test. One hundred and seventeen patients were surveyed. The mean patient EIS was 5.22 (IQR 4), while the mean physician EIS was less severe at 7.57 (IQR 3), a difference of 2.35 (p < 0.0001). Patient subgroups with the highest EIS compared to the physicians' EIS include those who were self-referred (difference of 2.65, p = 0.042), with income ≤ $25,000 (difference of 2.96, p = 0.004), with less than a college education (difference of 2.83, p = 0.018), and with acute-on-chronic musculoskeletal pain (difference of 4.17, p = 0.001). If we assume the physicians' EIS is closer to the true illness severity, patients with lower socioeconomic status, lower education status, who were self-referred, and who suffered from acute-on-chronic musculoskeletal pain are more likely to overestimate their illness severity and may contribute to non-urgent use of the ED. They may benefit from further education or resources for care to prevent ED misuse. The large difference of acute-on-chronic musculoskeletal pain may reflect a physician's bias to underestimate the severity of a patients' illness in this particular population.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

The French Emergency National Survey: A description of emergency departments and patients in France

INTRODUCTION

Some major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.

METHODS

The French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.

RESULTS

Among the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.

CONCLUSION

The French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage.

Emergency department utilisation for inflammatory bowel disease in the United States from 2006 to 2014

BACKGROUND

Despite advances in treatment, patients with inflammatory bowel disease (IBD) frequently require emergency department (ED) visits and hospitalisations.

AIMS

To analyse trends in ED visits and subsequent hospitalisations for IBD in the United States (US).

METHODS

Data were analysed from the Nationwide Emergency Department Sample (NEDS) years 2006-2014. The NEDS is the largest all-payer ED database in the US, weighted to represent 135 million visits/year. IBD was identified using ICD-9 codes for Crohn's disease (CD) or ulcerative colitis (UC). Surgeries were identified using procedure codes.

RESULTS

The frequency of IBD-ED visits increased 51.8%, from 90 846 visits in 2006 to 137 946 in 2014, which was statistically significant in linear regression. For comparison, all-case ED use between 2006 and 2014 increased 14.8%. In-patient hospitalisations from the ED decreased 12.1% for IBD (from 64.7% rate of hospitalisation from the ED in 2006 to 52.6% in 2014), with a UC:CD ratio of 1.2:1 in 2006 and 1.3:1 in 2014. Chi-square analysis revealed that this was a significant decrease. Surgery rates also showed a statistically significant decrease. The mean ED charge per patient rose 102.5% and the aggregate national cost of IBD-ED visits increased 207.5%. CD accounted for over twice as many visits as UC in both years. UC, age, male gender, highest income quartile, private insurance, Medicaid/Medicare, and tobacco use were associated with in-patient admissions.

CONCLUSIONS

The number of ED visits due to IBD and associated charges have continued to rise, while the rates of in-patient hospitalisations referred from the ED and surgeries have decreased.

Epidemiological characteristics of pediatric epistaxis presenting to the emergency department

OBJECTIVE

Investigate the epidemiological characteristics of pediatric epistaxis in the emergency department setting.

STUDY DESIGN

Cross-sectional study using national databases.

METHODS

Children (age <18 years) presenting with a diagnosis of epistaxis were extracted from the State Emergency Department Databases for New York, Florida, Iowa, and California for the calendar year 2010. Associated diagnoses, procedures, encounter characteristics, and demographic data were examined.

RESULTS

There were 18,745 cases of pediatric epistaxis (mean age 7.54 years, 57.4% male). Overall, 6.9% of patients underwent procedures to control epistaxis, of which 93.5% had simple anterior epistaxis control. The distribution of pediatric epistaxis was highest in spring and summer months (p < 0.001). Children from the lowest income quartile comprised a higher proportion of epistaxis presentations (38.8%, p < 0.001), yet were least likely to have an epistaxis control procedure performed (p < 0.001). Most patients had either Medicaid (43.8%) or private insurance (41.3%). Patients with Medicaid and those without healthcare coverage were least likely to undergo an epistaxis control procedure (p < 0.001). White children were more likely to undergo an epistaxis control procedure compared to those of minority backgrounds (p < 0.001).

CONCLUSIONS

Most emergency department presentations of pediatric epistaxis are uninvolved cases that do not require procedural intervention. The overrepresentation of low socioeconomic status patients may suggest an overutilization of emergency services for minor cases of epistaxis, and perhaps a lack of access to primary care providers. This is the first study to evaluate racial and socioeconomic factors in relationship to pediatric epistaxis. Further investigation is needed to better elucidate these potential disparities.

Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis

OBJECTIVES

Rising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.

METHODS

Systematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer-reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework-based narrative synthesis.

RESULTS

Thirty-eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty-nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency-based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.

CONCLUSIONS

We identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois

Introduction

This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012–2013) pre-ACA period and a 24-month post-ACA (2014–2015) period across 88 socioeconomically diverse areas of Illinois.

Methods

We used annual American Community Survey estimates for 2012–2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18–64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.

Results

The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012–2013, 2014–2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.

Conclusion

ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model

BACKGROUND

Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed.

OBJECTIVES

To compare access to pediatric surgical services between two coexisting PB and PV.

DESIGN

Retrospective comparative study.

SETTINGS

A major teaching hospital and the largest PV group in Saudi Arabia.

PATIENTS AND METHODS

The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS).

MAIN OUTCOME MEASURE(S)

TTS, SWT and DOS.

RESULTS

Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001).

CONCLUSION

When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar.

LIMITATIONS

Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.

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

BACKGROUND

There 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.

METHODS

The 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.

RESULTS

Care 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.

CONCLUSIONS

Urgent 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.

Reasons for Frequent Emergency Department Use by Medicaid Enrollees: A Qualitative Study

BACKGROUND

The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department (ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED.

METHODS

We conducted a qualitative data analysis of patient summary reports obtained from Medicaid enrolled frequent ED users who agreed to participate in a randomized control trial (RCT) evaluating the impact of patient navigation intervention compared with standard of care on ED use and hospital admissions. We defined frequent ED users as those who used the ED four to 18 times in the past year. The study was conducted at an urban, teaching hospital ED with approximately 90,000 visits per year. The research staff conducted interviews (~30-40 minutes), regarding the patient's medical history, reasons for ED visits, health care access issues, and social distresses. The aforementioned findings were summarized in a 1- to 2-page report and presented to the RCT's project team (social worker, emergency medicine physician, primary care physician, and patient navigators) on a weekly basis to further understand the needs of this patient population. A diverse team of researchers (program staff and physicians) coded all reports and reached consensus using reflexive team analysis. We reconciled differences in code interpretations and generated themes.

RESULTS

One-hundred patients enrolled in the RCT from March 2013 to February 2014, and all 100 patient summary reports were evaluated. We identified three key themes associated with Medicaid enrollee frequent ED use: 1) negative personal experiences with the healthcare system, 2) challenges associated with having low socioeconomic status, and 3) significant chronic mental and physical disease burden.

CONCLUSIONS

Medicaid frequent ED users engaged in receiving patient navigation services with the goal to reduce ED use and hospital admissions describe barriers that go beyond timely primary care access issues. These include sociodeterminants of health, lack of trust in primary care providers, and healthcare system.

Why Do Parents Bring Their Children to the Emergency Department? A Systematic Inventory of Motives

Parents frequently bring their children to general or pediatric emergency departments (EDs), even though many of these visits are judged by others to be "nonurgent" and inappropriate. This study examined the motives behind parents' decisions to take their children to a pediatric emergency department (PED). At a PED in Toulouse, France, 497 parents rated their level of agreement with each of 69 possible motives-representing all categories of human motivation-for coming to the PED that day. Exploratory and confirmatory factor analyses found evidence for six separable motives, called (in order of importance) (a) Seeking Quick Diagnosis, Treatment, and Reassurance; (b) PED as the Best Place to Go; (c) Empathic Concern for Child's Suffering; (d) Being Considered by Others as Responsible Parents; (e) External Factors; and (f) Dissatisfaction with Previous Consultation. Conclusions. Parents' motives in bringing their children to the PED are primarily serious and goal-oriented. They are also often emotion based, as would be expected in parents of ill children. The parents would be unlikely to agree that these visits were inappropriate.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study

BACKGROUND

The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization.

OBJECTIVE

Our aim was to characterize this population and their ED use at a national level.

METHODS

We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits.

RESULTS

NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43).

CONCLUSIONS

The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

Food Insecurity and Cost-Related Medication Underuse Among Nonelderly Adults in a Nationally Representative Sample

OBJECTIVES

We investigated whether nonelderly US adults (aged 18-64 years) in food-insecure households are more likely to report cost-related medication underuse than the food-secure, and whether the relationship between food insecurity and cost-related medication underuse differs by gender, chronic disease, and health insurance status.

METHODS

We analyzed data from the 2011 and 2012 National Health Interview Survey (n = 67 539). We examined the relationship between food insecurity and cost-related medication underuse with the χ(2) test and multivariate logistic regression with interaction terms.

RESULTS

Bivariate and multivariate analyses showed a dose-response relationship between food insecurity and cost-related medication underuse, with an increasing likelihood of cost-related medication underuse with increasing severity of food insecurity (P < .001). This association was conditional on health insurance status, but not substantially different by gender or chronic disease status. Being female, low-income, having no or partial health insurance, chronic conditions, functional limitations, or severe mental illness were positively associated with cost-related medication underuse.

CONCLUSIONS

Using food insecurity as a risk factor to assess cost-related medication underuse could help increase identification of individuals who may need assistance purchasing medications and improve health for those in food-insecure households.

Do Adult Medicaid Enrollees Prefer Going to Their Primary Care Provider's Clinic Rather Than Emergency Department (ED) for Low Acuity Conditions?

BACKGROUND

The rates of annual visits for adult Medicaid enrollees to the emergency department (ED) are increasing. Many programs throughout the country are focused on engaging patients in the use of their primary care providers (PCP) rather than the ED for low acuity conditions. It is unclear, however, the proportion of patients who are willing to use primary care services rather than the ED if they are given the choice.

METHODS

Cross-sectional study of adult Medicaid enrollees (18 y and older) presenting to a large, urban, academic ED from June to August 2012 with a low acuity condition was performed. We excluded patients who did not have a PCP or active Medicaid insurance. Our primary goal was to determine the proportion of patients who prefer to use the ED, rather than their PCP clinic, if an appointment was immediately available. Our second goal was to understand why patients would prefer ED over PCP care.

RESULTS

A total of 150 patients agreed to complete the survey, and 95 (63.3%) met our inclusion criteria. Forty-three patients (45.3%) stated preferring to use their PCPs rather than the ED if an appointment was available at that time. Thirteen (48.1%) cited that the ED had more technology or specialty care services available when compared with their PCP's clinic, 8 (15.4%) were in significant pain, and 6 (11.5%) felt the care they received in the ED was better than what they would receive in their PCP clinic.

CONCLUSIONS

Our study shows that a little less than half of adult Medicaid enrollees presenting to the ED with low acuity conditions would have preferred to use their PCP rather than the ED, if an appointment had been immediately available.

Why do people avoid medical care? A qualitative study using national data

BACKGROUND

Many studies have examined barriers to health care utilization, with the majority conducted in the context of specific populations and diseases. Less research has focused on why people avoid seeking medical care, even when they suspect they should go.

OBJECTIVE

The purpose of the study was to present a comprehensive description and conceptual categorization of reasons people avoid medical care.

DESIGN

Data were collected as part of the 2008 Health Information National Trends Survey, a cross-sectional national survey.

PARTICIPANTS

Participant-generated reasons for avoiding medical care were provided by 1,369 participants (40% male; M age =48.9; 75.1% non-Hispanic white, 7.4% non-Hispanic black, 8.5% Hispanic or Latino/a).

MAIN MEASURES

Participants first indicated their level of agreement with three specific reasons for avoiding medical care; these data are reported elsewhere. We report responses to a follow-up question in which participants identified other reasons they avoid seeking medical care. Reasons were coded using a general inductive approach.

KEY RESULTS

Three main categories of reasons for avoiding medical care were identified. First, over one-third of participants (33.3% of 1,369) reported unfavorable evaluations of seeking medical care, such as factors related to physicians, health care organizations, and affective concerns. Second, a subset of participants reported low perceived need to seek medical care (12.2%), often because they expected their illness or symptoms to improve over time (4.0%). Third, many participants reported traditional barriers to medical care (58.4%), such as high cost (24.1%), no health insurance (8.3%), and time constraints (15.6%). We developed a conceptual model of medical care avoidance based on these results.

CONCLUSIONS

Reasons for avoiding medical care were nuanced and highly varied. Understanding why people do not make it through the clinic door is critical to extending the reach and effectiveness of patient care, and these data point to new directions for research and strategies to reduce avoidance.

Food Insecurity and Health Outcomes Among Older Adults: The Role of Cost-Related Medication Underuse

The purpose of this study is to examine the relationship between food security and cost-related medication underuse among older adults (persons aged 65 years and older) in the United States; and to determine if this relationship differs by sex, chronic disease status, and type of health insurance. Data are from a combined sample of older adults in the 2011 and 2012 National Health Interview Survey (N = 10,401). Both bivariate and multivariate analyses show a dose-response relationship between food insecurity and cost-related medication underuse among the elderly--increasing likelihood of cost-related medication underuse with increasing severity of food insecurity (P < 0.001). This association is not conditional on sex, chronic disease status, or type of health insurance. However, females and those with a chronic condition are more likely to report cost-related medication underuse than males and those without a chronic condition respectively; and older adults with Medicare and Medicaid or other public insurance are less likely to report cost-related medication underuse than older adults with only Medicare.

Association of Medicare and Medicaid insurance with increasing primary care-treatable emergency department visits in the United States

OBJECTIVES

Policymakers have increasingly focused on emergency department (ED) utilization for primary care-treatable conditions as a potentially avoidable source of rising health care costs. The objective was to determine the association of health insurance type and arrival time, as indicators of limited availability of primary care, with primary care-treatable classification of ED visits.

METHODS

This was a retrospective analysis of a nationally representative sample of 241,167 ED visits from the 1997 to 2009 National Hospital Ambulatory Medical Care Surveys (NHAMCS). Probabilities of ED visits being primary care-treatable were categorized based on the primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code. The association of health insurance type and arrival time was determined with the average probability of the primary diagnosis being primary care-treatable using multivariable linear regression.

RESULTS

Compared to privately insured visits, Medicaid visits had a 1.7% (95% confidence interval [CI] = 1.2% to 2.2%) and uninsured visits a 2.4% (95% CI = 1.9% to 3.0%) higher probability of primary care-treatable classification, while Medicare visits had a 1.4% (95% CI = 0.7% to 2.0%) lower probability during the overall study period. Compared to business hours, weekend visits had a 1.5% (95% CI = 1.0% to 2.0%) higher probability of being primary care-treatable during the overall study period. From 1997 to 2009, the overall adjusted probability of ED visits being primary care-treatable increased by 0.19% (95% CI = 0.10 to 0.28) per year. This probability increased at a rate of 0.52% per year for Medicare visits (95% CI = 0.38% to 0.65%), more than double that of Medicaid visits (0.25% per year, 95% CI = 0.13% to 0.37%). By contrast, there was no significant change from 1997 to 2009 in the average probability of ED visits being primary care-treatable by privately insured (0.05% per year, 95% CI = -0.07 to 0.16) or uninsured (0.00% per year, 95% CI = -0.12 to 0.13) individuals.

CONCLUSIONS

These findings add to prior work that implicates insurance type and arrival time in the variation of primary care-treatable ED visits. Although primary care-treatable classification of ED visits was most associated with uninsured or Medicaid visits, this classification increased most rapidly among Medicare visits during the study period.

Correlates of hospital use in homeless and unstably housed women: the role of physical health and pain

PURPOSE

To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical health and pain.

METHODS

We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used.

RESULTS

Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio [OR], 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations.

CONCLUSIONS

Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.