- Email: [email protected]
Effect of a Systems-Based Approach on Reducing Emergency Department Use in an Integrated Health System
Research Forum Abstracts care visits. Physicians worked equally in all areas of the ED. Patient characteristics and encounter data were obtained from an electronic medical record and physician order entry system from August 2008 to January 2012. Urgent care visits, patients younger than age 8, and trauma activations were excluded. Physicians were excluded if they worked less than 200 clinical hours, had less than 50 observations of a given chief complaint, or worked primarily in the pediatric ED. Admission rates were modeled using Emergency Severity Index, patient age, and time of presentation with logistic regression to adjust for differences in patient populations between physicians. Adjusted admission rates were modeled for the chief complaints of abdominal pain, shortness of breath, chest pain, and headache. Odds ratios were calculated to determine whether physicians with high admission rates (upper quartile) were consistent across chief complaints. Results: There were 193,532 eligible ED visits, 57,213 of which resulted in admission. There were 48 emergency physicians who averaged 2,494 clinical hours and saw 3,949 patients during the study period. Each physician admitted an average of 1,168 patients. The adjusted overall admission rate was 23.5% (95%CI 22.9-24.3%) of ED visits, ranging from 17.4% (95%CI 16.2-18.6%) to 33.5% (95%CI 32.3-34.8%). The upper quartile of providers ordered 87% of admissions above the group average. There was large variation in admission rates between providers for all chief complaints. Shortness of breath had the highest admission rate among chief complaints, with 36.8% (range 17.1-53.0%) of visits resulting in admission. This was followed by abdominal pain (29.2%, 16.2-41.2%), chest pain (24.9%, 11.8-38.4%), and headache (15.3%, 5.4-26.7%). The odds ratio that high admitters for chest pain were high admitters for all patients was 34.0 (95%CI 5.84-197.8). High admission rates for shortness of breath (12.8, 95%CI 2.78-58.9) and abdominal pain (8.96, 95%CI 2.03-39.6) also predicted high overall admission rates. Odds ratios show high admitters of any one chief complaint were consistently high admitters for any one other chief complaint except headache. Conclusions: Large variation exists in provider admission rates for common chief complaints. A small group of providers appears to account for a significant volume of excess admissions in all chief complaints. Common factors may exist in this group that guide admission decisions. Chest pain and shortness of breath demonstrated the most variation among providers and appear to be good targets for interventions aimed at reducing unnecessary admissions.
160
New Metrics to Identify the Emergency Department Super User: Thinking Beyond the Number of Emergency Department Visits
Dorner S, Jenkins C, Liu D, Russ S, Heavrin BS/Vanderbilt University Medical Center, Nashville, TN
Study Objectives: The growth in emergency department (ED) utilization has fueled speculation that uninsured patients, acutely ill Medicaid patients, and patients without primary care providers seek care from EDs at disproportionately high levels. As such, patients who use EDs at levels well above the general population are commonly categorized as a single group - the super users. Previous studies seeking to analyze the super user patient population have predominantly used a metric of ED visits per unit time to define this population, usually with a threshold ranging from 2 - 12 yearly ED visits. This metric may or may not be optimal to define the resource burden of a population whose care begins in the ED. Our goal is to present an alternative metric for defining super users based on total charges that capture a different but important type of super user than one based on ED visits. Methods: This is an IRB-approved ecological study of patient data collected between May 1, 2011 and April 30, 2012 in the Vanderbilt University Hospital Adult ED. Patients with at least one ICU admission during the year were excluded from the analysis. Histograms and box plots were used to summarize yearly ED visits, hospital admissions, and total charges. Scatter plots of yearly ED visits by admissions for subgroups defined by quantiles of charges were created to investigate patterns in the data. Comparisons of supers users based on metrics of total ED visits and total charges were then compared. Results: There were a total of 44,577 patients who utilized the VUH Adult ED during the study period, representing 62,941 visits. After excluding subjects with one or more admission to the ICU, there were 32,997 subjects with 42,572 visits in the analysis. Scatter plots relating ED visits to the number of hospital admissions subgrouped by quantiles of total charges identified a change in the distribution pattern at the 90th percentile of total charges ($15,475). Subjects with total charges below the 90th percentile had no more than two admissions while all subjects with three or more admissions had total charges above the 90th percentile. Additionally, subjects in excess of the 90th percentile had either high ED-only visits (>12) with low admissions or a moderate number of visits with subsequent admissions. There were 3,300 super users by total charges. If we use the 90th percentile of visits as the threshold (2 visits) for
Volume 62, no. 4s : October 2013
super user status by visits, 1,786 subjects were identified as super users with 616 also being defined as super users by the total charge metric. Conclusions: Super users defined by total ED visits are not necessarily super users defined by total charge. Defining subjects who are high resource utilizers of the ED may require more than 1 metric to fully define the population. Graphical summaries of our data suggest thresholds applied to total charges can identify super users of the ED not fully captured with a metric based on ED visits. In addition, our metric based on charges also represents potential super users based on admissions as patients with 3 or more admissions were all super users based on charge.
161
Effect of a Systems-Based Approach on Reducing Emergency Department Use in an Integrated Health System
Isenberger KM, Salzman JG, Logue KA/Regions Hospital, St. Paul, MN; HealthPartners, Bloomington, MN
Study Objectives: The objective of this retrospective observational study was to evaluate the impact of a systems-based approach of five unique interventions on reducing the use of emergency departments for non-emergent conditions in an integrated health care delivery system. Methods: Beginning in 2009, our integrated care delivery system (HealthPartners, Inc., Bloomington, MN) began implementing 5 quality improvement projects to direct patients to the most appropriate setting for care. Those improvement methods included: 1) health plan based nurse triage system with algorithms to direct care (Careline), 2) an online nurse practitioner to care for minor illnesses (www.virtuwell. com), 3) implementation of an emergency department-based case manager, 4) use of the electronic medical record to ensure follow-up care in primary care post emergency department discharge, and 5) use of health plan patient risk stratification and no-show appointment lists to engage patients in care before needing emergency care. General linear models were used to determine if there was a reduction in a populationnormalized number of emergency department visits between 2009 and 2012. Covariates examined included insurance type (commercial vs. Medicaid) and season (Jan-Mar; Apr-Jun; Jul-Sept; Oct-Dec). The total cost of care (www.healthpartners. com/tcoc) specific to emergency services for the commercial population was also calculated and compared over the same 4 years. Results: Emergency department use for patients with commercial insurance products was significantly lower than patients with Medicaid as their primary payor (11.890.67 per 1000 vs. 49.164.26 per 1000; p < 0.001). Between 2009 and 2012, there was no reduction in emergency department visits in the commercial payor population. However, a seasonal utilization trend was noted, with higher usage in the 3rd quarter of each year compared to the 1st quarter and 4th quarters (p < 0.05 respectively). In the Medicaid population, there was a significant decrease in emergency room utilization between 2009 and 2010 (5.22 per 1000; p < 0.05) and 2009 and 2011 (7.22 per 1000; p < 0.05) but no seasonality noted. While the commercial population utilization did not decrease significantly over this period, total cost of care for HealthPartners members using the emergency department was 8% less than others in the same geographic metropolitan area. This equates to an annual health care cost avoidance of over $1.2 million. Conclusions: There is a strong association between emergency department use and payor type in our study population. Implementation of our systems-based approach did not appear to impact emergency department usage for those with commercial insurance, but did show a significant total cost of care savings in our organization compared to providers in the same geographic area. Our work appears to have impacted Medicaid patients most strongly.
162
U.S. Hospital Variation in Outpatient Treatment of Venous Thromboembolic Disease, 2010
Gibson Chambers J, Kabrhel C, Venkatesh AK, Schuur JD/University of New England, Biddeford, ME; Massachusetts General Hospital, Boston, MA; Yale University, New Haven, CT; Brigham and Women’s Hospital, Boston, MA
Background: Studies document the safety of outpatient management of deep venous thrombosis (DVT) and pulmonary embolism (PE) in selected patients after emergency department (ED) visits. It is not known whether hospitals vary in their treatment of DVT and PE and which hospital characteristics predict outpatient management. Study Objectives: Describe hospital-level variation and the degree to which hospital-level variation explains ED outpatient treatment rates for DVT and PE and examine hospital predictors of outpatient treatment.
Annals of Emergency Medicine S61
160
New Metrics to Identify the Emergency Department Super User: Thinking Beyond the Number of Emergency Department Visits
Dorner S, Jenkins C, Liu D, Russ S, Heavrin BS/Vanderbilt University Medical Center, Nashville, TN
Study Objectives: The growth in emergency department (ED) utilization has fueled speculation that uninsured patients, acutely ill Medicaid patients, and patients without primary care providers seek care from EDs at disproportionately high levels. As such, patients who use EDs at levels well above the general population are commonly categorized as a single group - the super users. Previous studies seeking to analyze the super user patient population have predominantly used a metric of ED visits per unit time to define this population, usually with a threshold ranging from 2 - 12 yearly ED visits. This metric may or may not be optimal to define the resource burden of a population whose care begins in the ED. Our goal is to present an alternative metric for defining super users based on total charges that capture a different but important type of super user than one based on ED visits. Methods: This is an IRB-approved ecological study of patient data collected between May 1, 2011 and April 30, 2012 in the Vanderbilt University Hospital Adult ED. Patients with at least one ICU admission during the year were excluded from the analysis. Histograms and box plots were used to summarize yearly ED visits, hospital admissions, and total charges. Scatter plots of yearly ED visits by admissions for subgroups defined by quantiles of charges were created to investigate patterns in the data. Comparisons of supers users based on metrics of total ED visits and total charges were then compared. Results: There were a total of 44,577 patients who utilized the VUH Adult ED during the study period, representing 62,941 visits. After excluding subjects with one or more admission to the ICU, there were 32,997 subjects with 42,572 visits in the analysis. Scatter plots relating ED visits to the number of hospital admissions subgrouped by quantiles of total charges identified a change in the distribution pattern at the 90th percentile of total charges ($15,475). Subjects with total charges below the 90th percentile had no more than two admissions while all subjects with three or more admissions had total charges above the 90th percentile. Additionally, subjects in excess of the 90th percentile had either high ED-only visits (>12) with low admissions or a moderate number of visits with subsequent admissions. There were 3,300 super users by total charges. If we use the 90th percentile of visits as the threshold (2 visits) for
Volume 62, no. 4s : October 2013
super user status by visits, 1,786 subjects were identified as super users with 616 also being defined as super users by the total charge metric. Conclusions: Super users defined by total ED visits are not necessarily super users defined by total charge. Defining subjects who are high resource utilizers of the ED may require more than 1 metric to fully define the population. Graphical summaries of our data suggest thresholds applied to total charges can identify super users of the ED not fully captured with a metric based on ED visits. In addition, our metric based on charges also represents potential super users based on admissions as patients with 3 or more admissions were all super users based on charge.
161
Effect of a Systems-Based Approach on Reducing Emergency Department Use in an Integrated Health System
Isenberger KM, Salzman JG, Logue KA/Regions Hospital, St. Paul, MN; HealthPartners, Bloomington, MN
Study Objectives: The objective of this retrospective observational study was to evaluate the impact of a systems-based approach of five unique interventions on reducing the use of emergency departments for non-emergent conditions in an integrated health care delivery system. Methods: Beginning in 2009, our integrated care delivery system (HealthPartners, Inc., Bloomington, MN) began implementing 5 quality improvement projects to direct patients to the most appropriate setting for care. Those improvement methods included: 1) health plan based nurse triage system with algorithms to direct care (Careline), 2) an online nurse practitioner to care for minor illnesses (www.virtuwell. com), 3) implementation of an emergency department-based case manager, 4) use of the electronic medical record to ensure follow-up care in primary care post emergency department discharge, and 5) use of health plan patient risk stratification and no-show appointment lists to engage patients in care before needing emergency care. General linear models were used to determine if there was a reduction in a populationnormalized number of emergency department visits between 2009 and 2012. Covariates examined included insurance type (commercial vs. Medicaid) and season (Jan-Mar; Apr-Jun; Jul-Sept; Oct-Dec). The total cost of care (www.healthpartners. com/tcoc) specific to emergency services for the commercial population was also calculated and compared over the same 4 years. Results: Emergency department use for patients with commercial insurance products was significantly lower than patients with Medicaid as their primary payor (11.890.67 per 1000 vs. 49.164.26 per 1000; p < 0.001). Between 2009 and 2012, there was no reduction in emergency department visits in the commercial payor population. However, a seasonal utilization trend was noted, with higher usage in the 3rd quarter of each year compared to the 1st quarter and 4th quarters (p < 0.05 respectively). In the Medicaid population, there was a significant decrease in emergency room utilization between 2009 and 2010 (5.22 per 1000; p < 0.05) and 2009 and 2011 (7.22 per 1000; p < 0.05) but no seasonality noted. While the commercial population utilization did not decrease significantly over this period, total cost of care for HealthPartners members using the emergency department was 8% less than others in the same geographic metropolitan area. This equates to an annual health care cost avoidance of over $1.2 million. Conclusions: There is a strong association between emergency department use and payor type in our study population. Implementation of our systems-based approach did not appear to impact emergency department usage for those with commercial insurance, but did show a significant total cost of care savings in our organization compared to providers in the same geographic area. Our work appears to have impacted Medicaid patients most strongly.
162
U.S. Hospital Variation in Outpatient Treatment of Venous Thromboembolic Disease, 2010
Gibson Chambers J, Kabrhel C, Venkatesh AK, Schuur JD/University of New England, Biddeford, ME; Massachusetts General Hospital, Boston, MA; Yale University, New Haven, CT; Brigham and Women’s Hospital, Boston, MA
Background: Studies document the safety of outpatient management of deep venous thrombosis (DVT) and pulmonary embolism (PE) in selected patients after emergency department (ED) visits. It is not known whether hospitals vary in their treatment of DVT and PE and which hospital characteristics predict outpatient management. Study Objectives: Describe hospital-level variation and the degree to which hospital-level variation explains ED outpatient treatment rates for DVT and PE and examine hospital predictors of outpatient treatment.
Annals of Emergency Medicine S61