Health Care Costs

AEM Early Acess 15: Predicting High ED Utilization Among Patients With Asthma Exacerbations

Welcome to the fifteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING: (open access through June 30, 2018; click on title to access.)

Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation. Margaret E. Samuels-Kalow, MD, MPhil, MSHP, Mohammad K. Faridi, MPH, Janice A. Espinola, MPH, Jean E. Klig, MD, and Carlos A. Camargo, Jr., MD, DrPH. Academic Emergency Medicine, 2018.

 

LISTEN NOW: AUTHOR INTERVIEW WITH DR. SAMUELS-KALOW

Recorded on site at SAEM 2018 in Indianapolis.  Stay tuned to the end for a BONUS about Dr. Samuels-Kalow's winning EXCITE project submission, addressing gender disparities and the 'leaky pipeline' of female leadership in academic emergency medicine. 

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Margaret Samuels-Kalow MD MPhil MSHP

Assistant Professor of Emergency Medicine

Massachusetts General Hospital/Harvard Medical School

ARTICLE SUMMARY:

Background: Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data.

Methods: To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike’s Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves.

Results: Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69–0.72), compared to 0.71 (95% CI = 0.69–0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76–0.77) and 0.76 (95% CI = 0.75–0.77), respectively.

Conclusion: Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).

ADDITIONAL READING:

"Looking out for each other": a qualitative study on the role of social network interactions in asthma management among adult Latino patients presenting to an emergency department. Pai S1, Boutin-Foster C, Mancuso CA, Loganathan R, Basir R, Kanna B. 
J Asthma. 2014 Sep;51(7):714-9. doi: 10.3109/02770903.2014.903967. Epub 2014 Apr 7.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma. Lawson CC1, Carroll K, Gonzalez R, Priolo C, Apter AJ, Rhodes KV. Acad Emerg Med 2014 Jan;21(1):1-8. doi: 10.1111/acem.12285.

Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med 2015;162:750-6.

Horrocks D, Kinzer D, Afzal S, Alpern J, Sharfstein JM. The Adequacy of Individual Hospital Data to Identify High Utilizers and Assess Community Health. JAMA Intern Med 2016;176:856-8.    

AEM Early Access 07: Patterns and Costs of Patients Visiting Multiple EDs

Welcome to the seventh episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

Discussing: (click on title for full text, open access through November 30, 2017)

Patients Visiting Multiple Emergency Departments: Patterns, Costs and Risk Factors

Todd W. Lyons MD, MPH, Karen L. Olson PhD,Nathan P. Palmer PhD, Reed Horwitz, Kenneth D. Mandl MD, MPH, Andrew M. Fine MD, MPH

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. TODD LYONS, MD MPH

Dr Todd Lyons

Dr. Todd Lyons, MD MPH

Clinical Instructor, Harvard Medical School

Staff Physician, Boston Children's Hospital

Article Summary

Objective: The authors of this study investigated the prevalence and impact of ED care fragmentation by characterizing the population of patients seeking care at multiple EDs and quantifying costs associated with this patient population.

 

Methods: This is a retrospective cohort study of insured patients who had one or more ED visit between 2010 and 2016. Outcomes investigated included number of EDs visited by each patient, the costs associated with this subset of patients, and factors associated with visiting multiple EDs.

 

Results: The study included 53,015,427 patients belonging to a single for-profit payer. Of this group, 8,651,716 patients had at least 1 ED visit and accounted for 16,390,676 ED visits resulting in  $26,102,831,740 in ED costs.

  • 20.5% of patients visited more than one ED but accounted for 41.4% of visits and 39.2% of costs

  • A small proportion (0.4%) of patients visited 5 or more EDs but accounted for 2.8% of ED visits and costs

  • Factors most strongly associated with visiting multiple EDs included age, living in the South, total years of enrollment and higher visit complexity

  • Diagnoses most strongly associated with visiting multiple EDs included alcohol and drug diagnoses and mental health disorders

 

Conclusion: A minority of patients seek care at multiple EDs but account for a significant cost burden. Characterization of this population suggests they represent higher complexity visits and are more likely to suffer from comorbid substance abuse and mental health conditions. The authors recommend further work to evaluate the impact of ED care fragmentation of care utilization and outcomes and recommend improving access to patient records to mitigate its effects.

SUGGESTIONS FOR FURTHER READING:

1.  Bourgeois FC, Olson KL, Mandl KD. Patients treated at multiple acute health care facilities: Quantifying information fragmentation. Arch Intern Med. 2010;170(22):1989-1995. 


2.  Cook LJ, Knight S, Junkins EP, Mann NC, Dean JM, Olson LM. Repeat Patients to the Emergency Department in a Statewide Database. Acad Emerg Med. 2004;11(3):256-263. 


3.  Fertel, Baruch S., Hart, Kimberly W., Lindsell, Christopher J., Ryan, Richard J., Lyons MS. Patients Who Use Multiple EDs: Quantifying the Degree of Overlap Between ED Populations. West J Emerg Med. 2015;49(2):229.