Shift in U.S. payer responsibility for the acute care of violent injuries after the Affordable Care Act: Implications for prevention

Background

Investment in violence prevention programs is hampered by lack of clearly identifiable stakeholders with a financial stake in prevention. We determined the total annual charges for the acute care of injuries from interpersonal violence and the shift in financial responsibility for these charges after the Medicaid expansion from the Affordable Care Act in 2014.

COVID-19 and emergency department volume: The patients return but have different characteristics

BackgroundThe COVID-19 pandemic has altered behaviors in the general population, as well as processes in the healthcare industry. Patients may be afraid to pursue care in the emergency department (ED) due to perceived risk of infection. The objective of this study was to determine the impact of COVID-19 on ED metrics.MethodsAt one metropolitan trauma center ED, we conducted a review of all visits from February to May in 2020 and compared findings with the same months from 2019.ResultsA total of 34,213 ED visits occurred during the study periods (18,471 in 2019 and 15,742 in 2020), with a decline in patient visits occurring after state emergency declarations. In 2020, patients were less likely to be female and more likely to arrive by ambulance. Diagnoses in the musculoskeletal, neurologic, and genitourinary categories occurred in lower proportions in 2020; toxicology, psychiatry, and infectious diseases occurred in higher proportions. In contrast to other insurance categories, Medicare patients comprised a larger share of ED visits in 2020 compared to 2019.DiscussionDespite relatively low local prevalence of COVID-19, we report decreases in ED volume for some medical diagnosis categories. A volume rebound occurred in May 2020, but did not reach 2019 levels. Public health officials should encourage local populations to seek emergency care when concerned, and could consider programs to provide transportation. Patients should continue to protect themselves with social distancing and masks.     

The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions

ObjectiveWe examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January–October 2020, compared to 2019, in a large sample of U.S. EDs.MethodsWe compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11–April 21), and later-pandemic (April 22–October 31) periods.ResultsED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020.ConclusionWe confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.     

Characterizing pediatric emergency department visits during the COVID-19 pandemic

ObjectiveWe determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs.MethodsUsing retrospective data from January–June 2020, compared to a similar 2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis.ResultsWe included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis.ConclusionPediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.     

Trends in outpatient emergency department visits during the COVID-19 pandemic at a large,urban, academic hospital system

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic.MethodsWe conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions.ResultsWhile outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020.ConclusionsOverall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.     

The influence of coronavirus disease 2019 on emergency department visits in Nanjing,China: A multicentre cross-sectional study

IntroductionInfluenza has been linked to the crowding in emergency departments (ED) across the world. The impact of the Coronavirus Disease 2019 (COVID-19) pandemic on China EDs has been quite different from those during past influenza outbreaks. Our objective was to determine if COVID-19 changed ED visit disease severity during the pandemic.MethodsThis was a retrospective cross sectional study conducted in Nanjing, China. We captured ED visit data from 28 hospitals. We then compared visit numbers from October 2019 to February 2020 for a month-to-month analysis and every February from 2017 to 2020 for a year-to-year analysis. Inter-group chi-square test and time series trend tests were performed to compare visit numbers. The primary outcome was the proportion of severe disease visits in the EDs.ResultsThrough February 29 ^th 2020, there were 93 laboratory-confirmed COVID-19 patients in Nanjing, of which 40 cases (43.01%) were first seen in the ED. The total number of ED visits in Nanjing in February 2020, were dramatically decreased (n = 99,949) in compared to January 2020 (n = 313,125) and February 2019 (n = 262,503). Except for poisoning, the severe diseases in EDs all decreased in absolute number, but increased in proportion both in year-to-year and month-to-month analyses. This increase in proportional ED disease severity was greater in higher-level referral hospitals when compared year by year.ConclusionThe COVID-19 outbreak has been associated with decreases in ED visits in Nanjing, China, but increases in the proportion of severe ED visits.     

The cases not seen: Patterns of emergency department visits and procedures in the era of COVID-19

ObjectivePrior data suggest Emergency Department (ED) visits for many emergency conditions decreased during the initial COVID-19 surge. However, the pandemic's impact on the wide range of conditions seen in EDs, and the resources required for treating them, has been less studied. We sought to provide a comprehensive analysis of ED visits and associated resource utilization during the initial COVID-19 surge.MethodsWe performed a retrospective analysis from 5 hospitals in a large health system in Massachusetts, comparing ED encounters from 3/1/2020–4/30/2020 to identical weeks from the prior year. Data collected included demographics, ESI, diagnosis, consultations ordered, bedside procedures, and inpatient procedures within 48 h. We compared raw frequencies between time periods and calculated incidence rate ratios.ResultsED volumes decreased by 30.9% in 2020 compared to 2019. Average acuity of ED presentations increased, while most non-COVID-19 diagnoses decreased. The number and incidence rate of all non-critical care ED procedures decreased, while the occurrence of intubations and central lines increased. Most subspecialty consultations decreased, including to psychiatry, trauma surgery, and cardiology. Most non-elective procedures related to ED encounters also decreased, including craniotomies and appendectomies.ConclusionOur health system experienced decreases in nearly all non-COVID-19 conditions presenting to EDs during the initial phase of the pandemic, including those requiring specialty consultation and urgent inpatient procedures. Findings have implications for both public health and health system planning.     

Evaluation of the Use of Telehealth Video Visits for Veterans With Chronic Pain

BackgroundTelehealth video visits are essential for delivering timely care while mitigating exposure during the COVID-19 pandemic. Telehealth video visits have the potential to improve missed appointments, reduce costs associated with Veterans Affairs (VA) travel reimbursement, and lead to positive patient and provider satisfaction.AimsThis evidence-based improvement project sought to evaluate whether telehealth visits reduce the occurrence of missed appointments, determine cost savings associated with the VA travel reimbursement and assess patient and provider satisfaction with telehealth video visits.DesignEvidence-based improvement project.SettingA retrospective chart review was conducted on military veterans with chronic pain who completed a telehealth video visit in the VA San Diego (VASD) pain clinic.MethodsMissed appointment rates were compared from before (April 1, 2019-October 1, 2019) to after (April 1, 2020-October 1, 2020) implementation of the telehealth video visits. Estimated travel reimbursement for qualified patients was calculated per VA policy. Electronic satisfaction surveys were administered to patients and nurse practitioners to assess satisfaction with telehealth video visits.ResultsThere was an 82.5% reduction in missed appointments from pre to post implementation of telehealth video visits. There was an estimated cost savings in travel reimbursements of $3,308.30. Overall, 93.62% of patients (n = 42) were satisfied with their video visits and there was a high degree of satisfaction in implementing video visits among the nurse practitioners (n = 3).ConclusionsThe use of telehealth video visits during the COVID-19 pandemic reduced missed appointments, exhibited cost savings in VA travel reimbursement, and led to positive patient and provider satisfaction.     

Racial disparities in insurance reimbursement for physician professional services in the ED

Objective

We sought to determine whether racial disparities exist in emergency physician professional services reimbursement from insurance. We hypothesized that insured adult African American emergency department (ED) visits are reimbursed at a lower level than White visits.

Methods

We conducted a retrospective, observational cohort study of insured adult White and African American ED visits (January 1, 2012, to June 30, 2013) to a tertiary center. We downloaded for each included visit age, sex, race, residential zip code, insurance type, admission status, Current Procedural Terminology (CPT) Evaluation and Management (E/M) code charge reimbursement, and median household income for residential zip code. We chose as our primary outcome measure visit mean total insurance reimbursement/work relative value unit (wRVU). We report racial variation for this outcome measure with 95% confidence intervals (CI) and present the β coefficient related to African American race within a multivariable regression model.

Results

A total of 50 297 visits met inclusion criteria (35 574 Whites and 14 723 African Americans). Overall, mean total insurance reimbursement/wRVU for White visits was $39.99 (95% CI, 39.80-40.18), for African American visits, $34.15 (95% CI, 33.88-34.42); P < .01. At the CPT E/M code level, African American visit reimbursement was lower than for White visits, ranging from $2.18/wRVU (95% CI, 0.87-3.49) (99282) to $7.55/wRVU (95 CI, 6.52-8.58) (99285). At the primary insurance level, African American visits showed lower reimbursement than White visits, ranging from $1.70/wRVU (95% CI, 0.75-2.65) in commercial insurance to $7.70/wRVU (95% CI, 5.42-9.98) in other insurance. Within the multivariable regression model, the β coefficient for African American race was −$1.51/wRVU (95% CI, −1.85 to −1.18); P < .001.

Conclusion

In this single-center study, professional services reimbursement was lower for African American ED visits compared with those of Whites.     

The Epidemiology of Emergency Department Trauma Discharges in the United States

Objective

Injury‐related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries.

Methods

We conducted a secondary retrospective, repeated cross‐sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all‐payer ED survey database in the United States. Main outcomes and measures were survey‐adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age‐stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey‐adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status.

Results

There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year‐to‐year decrease of 143 (95% CI = –184.3 to –68.5) visits per 100,000 U.S. population during the study period. The all‐age, all‐cause case‐fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case‐fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age‐stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm‐related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation‐adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion).

Conclusions

Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm‐related trauma presenting increased challenges.     

Standard nurse phone triage versus tele–emergency care pilot on Veteran use of in-person acute care: An instrumental variable analysis

Objectives

Use of acute care telemedicine is growing, but data on quality, utilization, and cost are limited. We evaluated a Veterans Affairs (VA) tele–emergency care (tele-EC) pilot aimed at reducing reliance on out-of-network (OON) emergency department (ED) care, a growing portion of VA spending. With this service, an emergency physician virtually evaluated selected Veterans calling a nurse triage line.

Methods

Calls to the triage line occurring January–December 2021 and advised to seek care acutely within 24 h were included. We described tele-EC user characteristics, common triage complaints, and patterns in referral to and management by tele-EC. The primary outcome was acute care visits (ED, urgent care, and hospitalizations at VA and OON sites) within 7 days of the index call. Secondary outcomes included mortality, OON acute care spending, and the effect of tele-EC visit modality (phone vs. video). We used both standard regression and instrumental variable (IV) analysis, using the tele-EC physician schedule as the instrument.

Results

Of 7845 eligible calls, 15.5% had a tele-EC visit, with case resolution documented in 57%. Compared to standard nurse triage, tele-EC users were less likely to be Black, had more prior ED visits, and were triaged as higher acuity. Calls concerning dizziness/syncope, blood in stool, and chest pain were most likely to have a tele-EC visit. Tele-EC was associated with fewer ED visits than standard nurse triage in both regression (average marginal effect [AME] −16.8%, 95% confidence interval [CI] −19.2 to −14.4) and IV analyses (AME −17.5%, 95% CI −25.1 to −9.8), lower hospitalization rate (AME −3.1%, 95% CI −6.2 to −0.0), and lower OON spending (AME –$248, 95% CI −$458 to −$38).

Conclusions

Among Veterans initially advised to seek care within 24 h, use of tele-EC compared to standard phone triage led to decreased ED visits, hospitalizations, and OON spending within 7 days.     

Decreased hospital admissions through emergency departments during the COVID-19 pandemic

Study objectiveEmergency Department (ED) visits decreased significantly in the United States during the COVID-19 pandemic. A troubling proportion of this decrease was among patients who typically would have been admitted to the hospital, suggesting substantial deferment of care. We sought to describe and characterize the impact of COVID-19 on hospital admissions through EDs, with a specific focus on diagnosis group, age, gender, and insurance coverage.MethodsWe conducted a retrospective, observational study of aggregated third-party, anonymized ED patient data. This data included 501,369 patient visits from twelve EDs in Massachusetts from 1/1/2019–9/9/2019, and 1/1/2020–9/8/2020. We analyzed the total arrivals and hospital admissions and calculated confidence intervals for the change in admissions for each characteristic. We then developed a Poisson regression model to estimate the relative contribution of each characteristic to the decrease in admissions after the statewide lockdown, corresponding to weeks 11 through 36 (3/11/2020–9/8/2020).ResultsWe observed a 32% decrease in admissions during weeks 11 to 36 in 2020, with significant decreases in admissions for chronic respiratory conditions and non-orthopedic needs. Decreases were particularly acute among women and children, as well as patients with Medicare or without insurance. The most common diagnosis during this time was SARS-CoV-2.ConclusionOur findings demonstrate decreased hospital admissions through EDs during the pandemic and suggest that several patient populations may have deferred necessary care. Further research is needed to determine the clinical and operational consequences of this delay.     

The impact of the COVID-19 pandemic and governor mandated stay at home order on emergency department super utilizers

BackgroundDespite the trend of rising Emergency Department (ED) visits over the past decade, researchers have observed drastic declines in number of ED visits due to the COVID-19 pandemic. The purpose of the current study was to examine the impact of the COVID-19 pandemic and governor mandated Stay at Home Order on ED super utilizers.MethodsThis was a retrospective chart review of patients presenting to the 12 emergency departments of the Franciscan Mission of Our Lady Hospital System in Louisiana between January 1, 2018 and December 31, 2020. Patients who were 18 years of age or older and had four ED visits within a one-year period (2018, 2019, or 2020) were classified as super-utilizers. We examined number and category of visits for the baseline period (January 2018 – March 2020), the governor's Stay at Home Order, and the subsequent Reopening Phases through December 31, 2020.ResultsThe number of visits by super utilizers decreased by over 16% when the Stay at Home Order was issued. The average number of visits per week rose from 1010.63 during the Stay at Home Order to 1198.09 after the Stay at Home Order was lifted, but they did not return to Pre-COVID levels of approximately 1400 visits per week in 2018 and 2019. When categories of visits were examined, this trend was found for emergent visits (p < 0.001) and visits related to injuries (p < 0.001). Non-emergent visits declined during the Stay at Home Order compared to the baseline period (p < 0.001), and did not increase significantly during reopening compared to the Stay at Home Order (p = 0.87). There were no changes in number of visits for psychiatric purposes, alcohol use, or drug use during the pandemic.ConclusionsSignificant declines in emergent visits raise concerns that individuals who needed ED treatment did not seek it due to COVID-19. However, the finding that super utilizers with non-emergent visits continued to visit the ED less after the Stay at Home Order was lifted raises questions for future research that may inform policy and interventions for inappropriate ED use.     

The impact of the COVID-19 pandemic on the utilization of emergency department services for the treatment of injuries

ContextThe global COVID-19 pandemic has had a major impact on the utilization of healthcare services; however, the impact on population-level emergency department (ED) utilization patterns for the treatment of acute injuries has not been fully characterized.ObjectiveThis study examined the frequency of North Carolina (NC) EDs visits for selected injury mechanisms during the first eleven months of the COVID-19 pandemic.MethodsData were obtained from the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), NC's legislatively mandated statewide syndromic surveillance system for the years 2019 and 2020. Frequencies of January – November 2020 NC ED visits were compared to frequencies of 2019 visits for selected injury mechanisms, classified according to International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) injury diagnosis and mechanism codes.ResultsIn 2020, the total number of injury-related visits declined by 19.5% (N = 651,158) as compared to 2019 (N = 809,095). Visits related to motor vehicle traffic crashes declined by a greater percentage (29%) and falls (19%) declined by a comparable percentage to total injury-related visits. Visits related to assault (15%) and self-harm (10%) declined by smaller percentages. Medication/drug overdose visits increased (10%), the only injury mechanism studied to increase during this period.ConclusionBoth ED avoidance and decreased exposures may have contributed to these declines, creating implications for injury morbidity and mortality. Injury outcomes exacerbated by the pandemic should be addressed by timely public health responses.     

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization

BackgroundThe novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes.ObjectiveWe aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization.MethodsWe reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks).ResultsThe total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted.ConclusionThe COVID-19 pandemic probably dissuaded “non-critical” patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).     

The effect of the COVID-19 pandemic on ED referrals and care for stroke patients: A four-year comparative study

PurposeTo examine the impact of the COVID-19 pandemic on the presentation and care provided to patients with acute ischemic stroke (AIS) at the emergency department (ED).MethodA retrospective-archive study was conducted between January-April 2020, compared with the parallel months in 2017–2019, in a comprehensive stroke center. We compared the time from symptoms onset to ED arrival, the number of neurologic consultations completed in the ED, patients diagnosed with AIS, patients receiving acute treatment and hospital mortality.ResultsDuring January-April 2020, we found an increase in the proportion of stroke patients arriving at the ED within 6 h of symptom onset: 68–100% per month during the study period, compared with 28–42% per month in the previous years. The number of patients admitted to the ED with suspected AIS declined by 41%, compared to the parallel period in 2019. An increase was noted in the number of patients diagnosed with AIS who underwent treatment, with the number of s endovascular thrombectomy increasing throughout the examined year.ConclusionDuring the COVID-19 pandemic, we observed a significant decline in the number of AIS patients admitted to the ED. Paradoxically, we have seen an increase in the proportion of patients who arrived shortly after the onset of symptoms and received timely treatment. Future studies might investigate the medical mechanism and ramifications of this phenomenon.     

The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population,Conditions Managed,and Reimbursement

Background

Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs).

Resource utilization and health care charges associated with the most frequent ED users

Study objective

Emergency department (ED) visits have continued to rise, and frequent ED users account for up to 8% of all ED visits. Reducing visits by frequent ED users may be one way to help reduce health care costs. We hypothesize that frequent users have unique ED utilization patterns resulting in differences in health care charges.

Methods

We conducted a retrospective review of electronic medical records from an urban community teaching hospital for the year 2012 comparing the top 108 frequent ED users (> 12 visits/year) to a randomly selected group of 108 nonfrequent users (< 4 visits/year). We compared demographic characteristics, distance lived from the hospital, medical and psychiatric history, substance abuse history, diagnostic testing, disposition, and amount charged to the patient for each visit. We compared data using χ² for proportions and t test or Wilcoxon rank sum based on normality of the data.

Results

The top 108 frequent ED users accounted for 1922 visits (2.9%), whereas the 108 nonfrequent users accounted for 150 visits (0.2%), in 2012 (all ED visits n = 65,398). Frequent users were more often unemployed, have public insurance, have mental health conditions, use tobacco, have a greater number of allergies to medications, and live closer to the hospital (P < .01). Disposition and median charge per visit did not differ between frequent and nonfrequent users ($1220 vs $1280). The total charges of the frequent ED users’ visits were $10,465,216.07 versus $1,012,610.21 for nonfrequent users.

Conclusions

Frequent users have unique medical and social characteristics; however, disposition and visit charges did not differ from nonfrequent users.