Emergency Department Visits St. Louis County, Missouri Saint Louis County Department of Public Health October 18, 2017

Transcription

1 Emergency Department Visits St. Louis County, Missouri Over the past few decades, emergency department (ED) visits have become a common phenomenon as increasingly more people seek medical care, not only for serious illnesses and injuries, but for nonemergency care as well. 1 For example, between 2003 and 2013, ED utilization increased by about 15% in the United States, up from million visits to million visits per year. 2, 3 The growing overutilization of EDs has serious implications for the U.S. healthcare system and the underlying reasons for the rise are important issues that require attention from all stakeholders. While the estimated $38 billion annual cost of ED visits has been described as wasteful spending, 4 the ED has also been described as the safety net of the U.S. healthcare system and it is often the only available option for care for those with limited or no access to regular or unscheduled medical care. 5, 6 As is the case across the nation, ED utilization is a significant issue in St. Louis County. This report presents data of ED utilization in St. Louis County, Missouri, from 2010 to During 2010 to 2014, there were 1.4 million ED encounters in St. Louis County. Women visited the ED at a higher rate than men, per 1,000 population compared to per 1,000 population. Residents younger than 45 years visited the ED more frequently than those 45 years and older, with the highest rate observed among those years old. St. Louis County residents in the Inner North region had the highest ED visit rate at per 1,000 population. St. Louis County residents living in medium, high, and very high poverty level neighborhoods had ED visit rates significantly higher than the overall county rate. African American/Black residents consistently had the highest ED visit rates compared to other racial/ethnic groups. Emergency Department Visits Figure 1. Age adjusted emergency department visits for St. Louis County, Missouri, and the United States, ED visits per 1,000 population YEAR St. Louis County Missouri United States* Sources: Missouri Department of Health and Senior Services (DHSS), Bureau of Health Care Analysis and Data Dissemination; National Center for Health Statistics. *Data based on National Hospital Ambulatory Medical Care Surveys from

2 Emergency Department Visits Page 2 of 30 Figure 1 shows the ED visit rates for St. Louis County, Missouri, and the United States. Overall, compared to both Missouri and the United States, St. Louis County had consistently lower ED visit rates between 2010 and However, the overall county rate does not paint the whole picture. When ED utilization is stratified by county geographic regions, which are particularly important in the context of St. Louis, there are notable disparities in ED utilization. Figure 2 highlights these disparities. Specifically, the Inner North has the highest rate of ED visits at per 1,000 population. The West has the lowest ED visit rate in the county at visits per 1,000 population. Figure 2. Age adjusted emergency department visits for St. Louis County and five St. Louis County regions, ED visits per 1,000 population St. Louis County Inner North Outer North Central South West State, County, and Five St. Louis County Geographic Subregions Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination

3 Emergency Department Visits Page 3 of 30 Table 1 presents results of five year averages of ED visits in St. Louis County by different demographic characteristics. From these data, we can see that during , African American/Black residents had ED visit rates higher than the county rate while all other racial/ethnic groups had rates that were significantly lower than the overall county rate. Table 1. Hospital emergency department visits per 1,000 population, St. Louis County, average. Rate 95% Confidence Interval Count per Year Missouri to ,249,991 St. Louis County to ,022 Age Group < 18 years to , years to , years to , years to , years and over to ,479 Sex Male to ,150 Female to ,870 Race/Ethnicity Asian to ,044 Black/African American to ,423 Hispanic or Latino to ,975 Multiple to ,249 White to ,193 Neighborhood Poverty* Very High to ,602 High to ,835 Medium to ,585 Low t ,000 Geographic Area Central to ,793 Inner North to ,252 Outer North to ,149 South to ,656 West to ,171 Comparisons: Higher than St. Louis County rate Lower than St. Louis County rate Notes: Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. Case Definition: Any visit to a hospital emergency department. Rates are age adjusted to the 2000 US population (not including Age Group rates).

4 Emergency Department Visits Page 4 of 30 Emergency Department Visits by Geography Map 1. Emergency department visits per 1,000 population by census tract, St. Louis County, Age-Adjusted Emergency Department Visit Rate per 1,000 Population < Zip Codes Unpopulated Uq !"f$ 63044!"f$ %&h( UN Un Iy!"e$ Iy!"e$ Un U U Un %&h( Iy!"e$ !"b$!"f$ City of St. Louis Iy!"e$!"b$ Iz!"c$ !"b$ Iz Iz!"c$ !"b$ Iz Iz %&j(!"c$ Miles Data Source: Missouri Department of Health and Senior Services Map 1 shows that the highest rates are located in the northern areas of the county, while the lowest rates are seen in the central and western regions.

5 Emergency Department Visits Page 5 of 30 Map 2. Emergency department visit rate by geographic area comparison, St. Louis County, Emergency Department Visit Rate Comparison Higher than St. Louis County rate Lower than St. Louis County rate Not signficantly different than St. Louis County rate Geographic Areas Unpopulated!"f$!"f$ Outer North %&h( Inner North Uq UN 364 Iy!"e$ Un West Un Iy!"e$ U Iy!"e$ %&h( Un Central!"f$ City of St. Louis Iy!"e$!"b$ Iz U!"b$!"c$!"b$ Iz Iz!"c$!"b$ Iz Iz South %&j(!"c$ Miles Data Source: Missouri Department of Health and Senior Services The Inner North has an average ED visit rate that is significantly higher than the rest of the county while the Outer North, Central, South, and West regions are significantly lower than the county rate (Map 2).

6 Emergency Department Visits Page 6 of 30 Figure 3. Age adjusted ED visit rates by geographic region, St. Louis County, Missouri, Age adjusted ED visit rate per 1,000 population St. Louis County Inner North Outer North Central South West Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Figure 3 shows the trend of ED visit rates for St. Louis County from for the five regions relative to the county overall. Generally, ED visit rates have been stable across all regions. An important point to note here is that from , the Outer North, Central, South, and West regions had similar or lower ED visit rates compared to the county. However, the Inner North consistently had the highest ED visit rates. Although, the Outer North saw a 13% increase in ED visits from 2010 to This steady rise from in 2010 peaked at per 1,000 population in 2013 before declining to in 2014 (Appendix 1.1).

7 Emergency Department Visits Page 7 of 30 Emergency Department Visits by Demographics Figure 4. Age adjusted ED visit rates by race, St. Louis County, Missouri, ED visit rates per 1,000 population St. Louis County Asian Black/African American Hispanic/Latino Multiple White Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Figure 4 shows the trend of ED visits for St. Louis County residents from , stratified by race and ethnicity. Compared to other racial groups, Black/African American residents consistently had the highest ED visit rates 3 to 17 times higher than other racial/ethnic groups. Of note, while Asian, Black/African American, Hispanic or Latino, and multiple race residents saw a significant increase in ED utilization from 2010 to 2014, White residents saw the opposite trend a 5% decline. The multiple races category had the highest increase in ED utilization during this time frame, jumping nearly 400% from 10.4 per 1,000 in 2010, to 55.2 per 1,000 in 2014 (Appendix 1.1). Figure 5. Age adjusted ED visit rates by sex, St. Louis County, ED visits per 1,000 population Year Female Male Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Similar to the overall county rate from , the ED visit rate for men in 2010 was essentially the same as it was in The rate for women increased by 3% from 2010 to 2014 (Figure 5 and Appendix 1.1). An important point worth noting is that there was a wide disparity in ED utilization by sex. Specifically, women were 1.2 to 1.4 times more likely to visit the ED than men during this period.

8 Emergency Department Visits Page 8 of 30 Figure 6. Age specific ED visit rates for St. Louis County, Age specific ED visit rates per 1,000 population Year < Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Figure 6 shows ED utilization rates stratified by five age groups. As evident from the graph, during , those between the ages of 18 and 24 consistently had the highest ED visit rates compared to any other age groups, with an average of 454 visits per 1,000 population per year. The youngest age group (<18 years) had the second highest ED utilization rate. All the age groups 44 years and younger had ED visit rates that were higher than the overall county rates (Appendix 1.1).

9 Emergency Department Visits Page 9 of 30 Leading Causes of ED Visits Table 2 shows the leading reasons (i.e., major disease category classified by International Classification of Disease, ninth edition codes ICD9) why residents sought care from in EDs. During this time, there were a total of 1.4 million ED visits an average of 291,000 visits per year. The most common major disease category for ED visits was injury and poisoning, which accounted for nearly a quarter of all ED visits (23.5%) during this time period. Among this group, sprains and strains, as well as open wounds were the most common reasons for ED visits. Poisonings and toxic effects made up only 2.4% of the injury and poisoning disease category. Symptoms, signs, and ill defined conditions (including symptoms involving nervous, musculoskeletal, cardiovascular, respiratory, digestive, urinary, head and neck as well as sudden death with unknown causes, senility, and other ill defined and unknown causes of morbidity and mortality) followed closely at 21.7%. Rounding out the top five are diseases of the respiratory system (10%), diseases of the musculoskeletal system and connective tissue (7.7%), and diseases of the digestive system (6.2%). Table 2. Number of visits by primary diagnosis at emergency department visit, classified by major disease category: St. Louis County, Missouri, Major disease category ICD 9 CM code range Number of ED Visits Percent distribution All ED visits 1,455, Infectious and parasitic diseases , Neoplasm , Endocrine, nutritional, metabolic diseases, and immune , disorders Mental disorders , Diseases of the nervous system and sense organs , Diseases of the circulatory system , Diseases of the respiratory system , Diseases of the digestive system , Diseases of the genitourinary system , Diseases of the skin and subcutaneous tissue , Diseases of the musculoskeletal system and connective tissue , Symptoms, signs, and ill defined conditions , Injury and poisoning , Fractures , Sprains and strains , Intracranial injury , Open wounds , Superficial injury , Contusion with intact skin surface , Foreign bodies , Burns , Trauma complications and unspecified injuries , Poisoning and toxic effects , Surgical and medical complications , Other injuries 20, Supplementary Classification V01 V89 34, Others* 42, *includes other diagnosis not included in these ICD 9 CM code ranges, and those with missing primary diagnosis.

10 Emergency Department Visits Page 10 of 30 Table 3 shows the 20 leading primary diagnoses by specific ICD 9 CM codes for ED visits in St. Louis County from , ranked in order. By this criteria, acute upper respiratory infections such as tonsillitis, laryngitis, influenza, and the common cold were the leading reasons for ED visits, which made up only 2.1% of the patients. This was closely followed by headache, chest pain, abdominal pain, and urinary tract infection. Table 3. Twenty leading primary diagnosis at emergency department visit by specific ICD 9 CM codes: St. Louis County, Missouri, Primary Diagnosis ICD 9 CM code Number of ED Visits Percent distribution All ED visits 1,455, Acute upper respiratory infections , Headache , Chest pain, unspecified , Abdominal pain, unspecified site , Urinary tract infection, site not specified , Unspecified otitis media , Head injury, unspecified , Other and unspecified noninfectious gastroenteritis and colitis , Other Chest pain , Abdominal pain, other specified site , Acute pharyngitis , Sprain of neck , Lumbago , Asthma, unspecified type, with (acute) exacerbation , Pain in limb , Dizziness and giddiness , Open wound of finger(s), without mention of complication , Unspecified disorder of the teeth and supporting structures , Extrinsic asthma , Sprain of ankle, unspecified site , Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. When only looking at adults 18 years and older, symptoms, signs, and ill defined conditions were the most common primary diagnosis, followed by injury and poisoning (Figure 7). These are similar to the most recent national figures, where the four most common diagnoses of major disease categories are essentially the same as those in our data. 3 Please see Appendix 2.1 for more details.

11 Emergency Department Visits Page 11 of 30 Figure 7. Number of visits by primary diagnosis at emergency department visit, classified by major disease category for adults 18 years: St. Louis County, Missouri, Symptoms, signs, and ill defined conditions 256,048 Injury and poisoning 235,426 Diseases of the musculoskeletal system and connective tissue Diseases of the respiratory system 77, ,366 Major disease category Diseases of the genitourinary system Diseases of the digestive system Others* Diseases of the skin and subcutaneous tissue Diseases of the nervous system and sense organs 71,031 68,766 59,657 44,681 43,279 Mental disorders 37,849 Diseases of the circulatory system 29,549 Infectious and parasitic diseases Endocrine, nutritional, metabolic diseases, and immune disorders Neoplasm 14,801 1,543 21, , , , , , ,000 ED visits for adults 18 years Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. *Includes other diagnosis not included in these ICD 9 CM code ranges, those with supplementary classification and those with missing primary diagnosis. Figure 8 shows the number of ED visits based on primary diagnosis stratified by major disease categories among children under the age of 18 years. In St. Louis County, from , the most common reason for ED visits was injury and poisoning, accounting for nearly one third of the ED visits. This was followed by diseases of the respiratory system, which accounted for another 19% of the ED visits. Please see Appendix 2.2 for more details. It is important to point out that injury and poisoning is a broad category of diagnosis and includes any patients who were injured without being poisoned. Those with alcohol and drug abuse, for example, are also included in this category. It really represents injury and/or poisoning.

12 Emergency Department Visits Page 12 of 30 Figure 8. Number of visits by primary diagnosis at emergency department visit, classified by major disease category for children less than 18 years: St. Louis County, Missouri, Injury and poisoning 107,019 Diseases of the respiratory system 74,801 Symptoms, signs, and ill defined conditions 59,834 Major disease category Diseases of the nervous system and sense organs Infectious and parasitic diseases Diseases of the digestive system Diseases of the skin and subcutaneous tissue Others* Diseases of the musculoskeletal system and connective tissue Diseases of the genitourinary system Mental disorders Endocrine, nutritional, metabolic diseases, and immune disorders Diseases of the circulatory system Neoplasm 37,872 25,618 21,087 20,851 16,989 10,477 8,744 6,912 1, All pediatrics ED visits Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. *Includes other diagnosis not included in these ICD 9 CM code ranges, those with supplementary classification and those with missing primary diagnosis. Figure 9 shows the number of ED visits based on primary diagnosis stratified by major disease categories among those 18 to 24 year old residents, a group that had the highest rate of ED visits in the county. Among this group, from , the most common diagnosis at ED visit was injury and poisoning, accounting for one in five ED visits in this age group. This was followed by symptoms, signs and illdefined conditions, which accounted for another 19% of the ED visits. It is important to point out that injury and poisoning is a broad category of diagnosis and includes any patients who were injured without being poisoned. Those with alcohol and drug abuse, but no injury, for example, are also included in this category. It is important to mention that the category Others also covers those with supplementary classifications (ICD 9 CM code ranges: V01 V89), which includes pregnancies and deliveries a potentially common reason why this age group may have higher ED visit rates.

13 Emergency Department Visits Page 13 of 30 Figure 9. Number of visits by primary diagnosis at emergency department visit, classified by major disease category for residents 18 to 24 years: St. Louis County, Missouri, Injury and poisoning Symptoms, signs, and ill defined conditions 30,906 28,350 Major disease category Others* Diseases of the genitourinary system Diseases of the respiratory system Diseases of the digestive system Diseases of the musculoskeletal system and connective tissue Diseases of the skin and subcutaneous tissue Diseases of the nervous system and sense organs Mental disorders Infectious and parasitic diseases 16,271 15,311 12,331 9,276 7,479 7,451 5,621 5,583 5,390 Endocrine, nutritional, metabolic diseases, and immune disorders Diseases of the circulatory system Neoplasm All ED visits for 18 to 24 years old Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. *Includes other diagnosis not included in these ICD 9 CM code ranges, those with supplementary classification and those with missing primary diagnosis.

14 Emergency Department Visits Page 14 of 30 Differences by Geographic Area and Gender Map 3. Top five reasons for ED visit by geographic regions, St. Louis County, Injury and poisoning 2. Symptoms, signs, and ill defined conditions 3. Diseases of the respiratory system 4. Diseases of the musculoskeletal system and connective tissue 5. Diseases of the digestive system 1. Symptoms, signs, and ill defined conditions 2. Injury and poisoning 3. Diseases of the respiratory system 4. Diseases of the musculoskeletal system and connective tissue 5. Diseases of the digestive system 1. Injury and poisoning 2. Symptoms, signs, and ill defined conditions 3. Diseases of the musculoskeletal system and connective tissue 4. Diseases of the respiratory system 5. Diseases of the digestive system!"f$!"f$ Outer North %&h( Inner North Uq UN 364 Iy!"e$ Un West Un Iy!"e$ U Iy!"e$ %&h( Un Central!"f$ City of St. Louis Iy!"e$!"b$ Iz U!"b$!"c$!"b$ Iz Iz!"c$!"b$ Iz Iz South %&j(!"c$ Miles Data Source: Missouri Department of Health and Senior Services 1. Injury and poisoning 2. Symptoms, signs, and ill defined conditions 3. Diseases of the respiratory system 4. Diseases of the musculoskeletal system and connective tissue 5. Diseases of the digestive system 1. Injury and poisoning 2. Symptoms, signs, and ill defined conditions 3. Diseases of the musculoskeletal system and connective tissue 3. Diseases of the respiratory system 5. Diseases of the digestive system

15 Emergency Department Visits Page 15 of 30 Map 3 shows the top five reasons for ED visits in the five St. Louis County subregions. Although there were some variations in terms of which diagnosis was most common at ED visits in the different subregions, the same disease categories remained in the top five throughout the county. The leading reason for ED visits, injury and poisoning, was the same across the county, except in the Inner North subregion, where symptoms, signs, and ill defined conditions was the most common diagnosis. The five most common reasons for ED visits were selected and age adjusted ED visit rates were calculated for these disorders among St. Louis County residents. The results are presented in Table 4. For injury and poisoning, the ED visit rate in St. Louis County from was 71 per 1,000 population, accounting for approximately 68,000 ED visits per year during this time period. Table 4. Age adjusted ED visits per 1,000 population for the five most common diagnoses at ED visit, St. Louis County, average. Major Disease Categories Rate 95% Confidence Interval Count per Year Injury and poisoning to ,489 Symptoms, signs, and ill defined conditions to ,176 Diseases of the respiratory system to ,430 Diseases of the musculoskeletal system and connective tissue to ,369 Diseases of the digestive system to ,971 Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. Rates are age adjusted to the 2000 US population (not including Age Group rates). Figures 10. The top five reasons for ED visits stratified by gender Symptoms, signs, and ill defined conditions Injury and Poisoning 120, , , ,291 Diseases of the respiratory system Diseases of the musculoskeletal system and connective tissue Diseases of the digestive system 67,636 84,516 43,655 68,188 38,357 61, Men Women Figure 10 show the leading reasons for ED visits stratified by gender among St. Louis County residents. Across all major disease categories, women had a higher number of ED visits as compared to men. While symptoms, signs, and ill defined conditions was the number one diagnosis among women at ED visits, injury and poisoning was the leading diagnosis for men.

16 Emergency Department Visits Page 16 of 30 Charges at ED Visits It is important to mention at the outset that charges do not mean costs and are often not the best proxy for costs. This is because what is often designated as a charge is not what is actually paid in the end. From , the total charges for the 1.4 million St. Louis County residents who visited the ED was just over $2.9 billion, at an average charge of $2,006 per visit (Table 5). Adults in St. Louis County were charged a total of approximately $2.5 billion, while children under the age of 18 were charged $437 million for emergency care (see Appendix 3.1 and 3.2 for more details). Table 5. Total charges for the number of visits by primary diagnosis groups at emergency department visits: St. Louis County, Missouri, Major disease category Total charges ICD 9 CM code range Average charges All ED visits among adults $2,006 $2,919,422,246 Infectious and parasitic diseases $1,171 $54,627,558 Neoplasm $3,502 $5,763,513 Endocrine, nutritional, metabolic diseases, and $2,279 $37,724,288 immune disorders Mental disorders $2,210 $98,939,650 Diseases of the nervous system and sense organs $1,313 $106,548,707 Diseases of the circulatory system $2,691 $81,280,356 Diseases of the respiratory system $1,407 $214,139,170 Diseases of the digestive system $1,935 $173,877,355 Diseases of the genitourinary system $2,704 $215,737,894 Diseases of the skin and subcutaneous tissue $1,093 $71,604,655 Diseases of the musculoskeletal system and $1,768 $197,737,961 connective tissue Symptoms, signs, and ill defined conditions $2,794 $882,585,459 Injury and poisoning $1,882 $644,639,238 Fractures $2,321 $95,765,492 Sprains and strains $1,652 $123,667,097 Intracranial injury $3,243 $22,076,336 Open wounds $1,659 $118,889,562 Superficial injury $1,207 $24,509,061 Contusion with intact skin surface $1,982 $90,589,440 Foreign bodies $1,227 $7,824,980 Burns $1,093 $5,281,982 Trauma complications and unspecified injuries $2,649 $94,584,835 Poisoning and toxic effects $1,838 $14,933,968 Surgical and medical complications $1,793 $10,601,235 Other injuries $1,717 $35,915,250 Supplementary Classification V01 V89 $1,335 $45,795,311 Others* $2,088 $88,421,124 *includes other diagnoses not included in these ICD 9 CM code ranges, those with supplementary classification, and those with missing primary diagnosis.

17 Emergency Department Visits Page 17 of 30 Figure 11. Percent of ED visits categorized by insurance type: St. Louis County, Missouri, % 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Public Private Other Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. Insurance type defined by expected source of payment. Public includes Medicare managed and not managed, Medicaid managed and not managed, and other government, managed and not managed; private includes all commercial managed and not managed and workers comp managed and not managed, Figure 11 shows the percentage of ED visits categorized by insurance type. These insurance types were categorized based on the expected sources of payment. While it is evident that many of the ED visits were by those on some kind of public insurance, it is important to note that a third of all visits were by those with some kind of private insurance. Figure 12. Age adjusted ED visit rates for self pay stratified by five geographic regions in St. Louis County, Age adjusted ED visit rate per 1,000 population Outer North Inner North St. Louis County Central South West Self pay for medical care is often used as a proxy for lack of insurance. 7 There were 282,330 people who were categorized as self paying patients during Age adjusted ED visit rates were calculated for this group, stratified by the five geographic subregions (Figure 12). The Inner North and Outer North subregions had higher age adjusted rates than the overall county. This is an important finding because both the Inner North and Outer North have the highest poverty levels relative to the rest of the county (Map 3). Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination

18 Emergency Department Visits Page 18 of 30 Access to Care Research has shown that lack of access to primary care is often associated with increased utilization of EDs. 8 Moreover, lack of insurance and poverty have been found to be strongly correlated with primary care related ED visits. In St. Louis County, access to and the availability of high quality primary health care, especially for populations with chronic health conditions, is inconsistent. According to the 2011 St. Louis County Community Health Needs Assessment (CHNA), county residents who had access to a usual source of care (i.e., primary care), were less likely to utilize EDs or hospital outpatient clinics for their care. 9 As a result, access to care was identified as one of four Community Health Improvement Plan (CHIP) priorities. 10 The present data also confirm the findings of the 2011 survey, which found that ED utilization and hospitalization rates varied by geographic regions, with North County having higher rates compared to the rest of the county, both for insured and uninsured residents. Figure 12. Percent of uninsured population in St. Louis County, Missouri, and the United States, Figure 12 shows the percentage of St. Louis County residents who are uninsured as compared to both state and national 12 figures. Assessment of insurance coverage is important for 10 understanding the potential magnitude and distribution of ED utilization in St. Louis County. As shown in Figure 12, compared to both Missouri and the United States uninsured populations from , St. Louis County consistently had a smaller percent of its population St. Louis County Missouri United States uninsured. This graph essentially follows the same pattern as ED visit rates in St. Louis County, Source: American Community Survey Missouri, and the United States (Figure 1). Notably, although the rate of uninsured has been on a steady decline since the passage of the Affordable Care Act (ACA), the rate of ED visits has not decreased. However, the fact that the state of Missouri did not expand Medicaid may contribute to ED use by those without insurance. Moreover, this may point to the negative effects of other equally important predictors of ED utilization such as poverty. The Healthy People 2020 goal is to increase the proportion of persons with medical insurance to 100%. Percent of Uninsured Population

19 Emergency Department Visits Page 19 of 30 Similarly, when the uninsured in St. Louis County were stratified by the five subregions, it became evident that the areas with the highest ED visit rates (Figure 2 and Map 1) are also the same areas with the highest proportion of uninsured residents (Figure 13 and Map 4). The Inner North has the highest percentage of uninsured residents in the county at 18.2%. In contrast, the West has the lowest proportion of uninsured at 4.9% (Figure 13). When comparing the map of ED visit rates (Map 1) and the map of insurance coverage (Map 4), the similarities are noteworthy. Figure 13. Percent of population without insurance in St. Louis County stratified by five county subregions, Percent of Uninsured St. Louis County 18.2 Inner North 12.0 Outer North Central South West Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Figure 14. Age adjusted ED visit rates by neighborhood poverty level, St. Louis County, ED visit rates per 1,000 population Very High High Medium Low Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination Poverty has been found to be an important risk factor of ED utilization in the United States. In St. Louis County, from , the average ED visit rate varied significantly by neighborhood poverty level (Figure 14). Not surprisingly, neighborhoods with very high poverty had the highest ED visit rate at per 1,000 population, closely followed by neighborhoods with high poverty. This was more than double the countywide rate and three times the rate of neighborhoods with low poverty. ED visit rates in neighborhoods with very high and high poverty are essentially the same as those for the Inner North and parts of the Outer North regions (Maps 1 and 2). These are both areas of concentrated poverty and high uninsured populations (Maps 3 & 4).

20 Emergency Department Visits Page 20 of 30 Map 4. Map of neighborhood poverty level by St. Louis County census tracts, Neighborhood Poverty Level Low Medium High Very High Geographic Areas Unpopulated Outer North Uq!"f$!"f$ %&h( Inner North UN 364 Iy!"e$ Un West Un Iy!"e$ U Iy!"e$ %&h( Un Central!"f$ City of St. Louis Iy!"e$!"b$ Iz U!"b$!"c$!"b$ Iz Iz!"c$!"b$ Iz Iz South %&j(.!"c$ Miles Data Source: American Community Survey,

21 Emergency Department Visits Page 21 of 30 Map 5. Percentage of uninsured non institutionalized St. Louis County residents by census tract, Percent Uninsured Zip Codes Unpopulated Area 63045!"f$ %&h(!"f$ Uq UN Un Iy!"e$ Iy!"e$ Un U U Un %&h( Iy!"e$ !"b$!"f$ City of St. Louis Iy!"e$!"b$ Iz!"c$ 63088!"b$ Iz Iz!"c$ !"b$ Iz Iz %&j(.!"c$ Miles Data Source: American Community Survey,

22 Emergency Department Visits Page 22 of 30 Risk Factors A number of factors have been identified as primary drivers of ED utilization. These include: lack of access to primary care services, lack of health insurance, having public insurance, homelessness, and low socioeconomic status Other factors that have been found to be associated with increased ED utilization include: availability of specialty care in hospitals, referrals by primary care doctors, misdiagnosis, and worsening of disease symptoms. 4 In the case of St. Louis County, it is important to note that the wide disparities in ED utilization highlighted by this report directly correlate with known risk factors such as lack of insurance, limited access to primary care services, and poverty. For instance, ED utilization in St. Louis County is greatest in the areas where there is a high concentration of minority populations, concentrated poverty, and areas where insurance coverage is below the rest of the county. From a public health perspective, identification of these risk factors can help policy makers and various stakeholders institute policies to address this problem. Methods Data was obtained from the Missouri Department of Health and Senior Services, the Bureau of Health Care Analysis and Data Dissemination for the years The data received captures all Emergency Department (ED) visits for St. Louis County residents. ED visits were identified by selecting hospital outpatient encounters that were served in acute medical/surgical units. Unfortunately, these are only ED encounters and do not identify individuals with multiple visits. Various diseases and disease categories were classified using the International Classification of Diseases, Ninth Revision (ICD 9) primary diagnosis codes. The ICD 9 CM code ranges used for classifying major disease categories were based on National Center for Health Statistics grouping criteria. 3 ED visit expenditures were calculated based on total charges those associated with revenue code 001 rounded to the nearest dollar. It is important to point out that charges are not the same as costs or revenue. The American Community Survey (ACS) was used to generate 1 year and 5 year estimates for the St. Louis County population by age, gender, race, and Hispanic origin for Population based rates (calculated using the number of events ED visits divided by the estimated population size for the same demographic group and year) reflect the overall burden on the general population. The percent of residents living below the federal poverty level for each census tract was also obtained from ACS using the 5 year estimate for In the analysis, neighborhood poverty level was assigned to each ED encounter based on residence within each St. Louis County 2010 census tract F1Each census tract was assigned one of four categories based on its percentage of residents below the federal poverty level: Low (0 to < 10 percent); Medium (10 to <20 percent); High (20 to <30 percent); and Very high (30 to 100 percent). Age adjusted and agespecific rates and 95% confidence intervals were calculated in Microsoft Excel using population estimates from ACS. The rates were age adjusted to the 2000 U.S. population. 15 1FGeographic regions were determined from the Saint Louis County Planning Division region maps by assigning each census tract a matching region. Maps were generated using ArcGIS for the vital statistics data for rates by zip code and geographic regions. Healthy People is an initiative created by the U.S. Department of Health and Human Services to provide evidence based, 10 year goals and objectives to improve the nation s health and well being. Healthy People 2020 is the fourth Healthy People initiative; the first was Healthy People 1990: Promoting Health/Preventing Disease: Objectives for the Nation. Healthy People objectives were created involving

23 Emergency Department Visits Page 23 of 30 input from many individuals and organizations to monitor the nation s progress and motivate change that will prevent further disease. Resources A number of strategies have been proposed to reduce ED utilization. These include improving access to primary care, expanding insurance coverage (Missouri has not expanded Medicaid to comply with the Affordable Care Act), and improving the management of chronic diseases. 4 Additional ways to reduce ED visits include ED diversion strategies such as: community education initiatives, nurse operated telephone triage systems, hospital ED screenings, the development of urgent care centers, and increasing primary care capacity among safety net providers. 16 In the St. Louis region, there are several primary care safety net institutions where individuals can access primary care services. 17 These include: Affinia Healthcare Barnes Jewish Hospital OB/GYN Clinic Barnes Jewish Hospital Medicine Clinic Betty Jean Kerr People s Health Centers Family Care Health Centers Mercy JFK Clinic Myrtle Hilliard Davis Comprehensive Health Centers SLUCare Saint Louis County Department of Public Health St. Luke s Pediatric Clinic SSM Health Cardinal Glennon/Glennon Care at DePaul SSM Health St. Mary s Health Center The SPOT (Supporting Positive Opportunities with Teens) Other resources available to St. Louis County residents include a number of urgent care centers located across the county. Another resource that is available is the Community Referral Coordinator (CRC) Program. The CRC Program uses community referral coordinators to connect patients in inpatient units and/or EDs with a primary care provider for follow up and preventative care. CRCs work to ensure that established community health center patients are reconnected to their primary care homes and that those patients identified as having a chronic disease establish PCP care following their hospitalization. The goals of the program are to: 1) enhance access to a primary care home and health resources for all patients regardless of ability to pay; 2) reduce non emergency use of EDs and low acuity readmissions; 3) enhance continuity of care; and 4) strengthen communications/processes among safety net providers. An FY2017 goal is developing a plan for the United Way intersection with P.U.L.S.E. in St. Louis and Missouri. The CRC program currently has ten community referral coordinators in eight hospital sites.

24 Emergency Department Visits Page 24 of 30 Acknowledgements This report would not be complete without guidance from the leadership of the department: Dr. Faisal Khan, Director of the Saint Louis County Department of Public Health; Spring Schmidt, Director of the Division of Health Promotion and Public Health Research; Dr. Emily Doucette, Director of the Division of Primary Care and Public Health Integration; Dr. Fredrick Echols, Director of the Division of Communicable Diseases Control Services; and Carrie Dickhans, Director of the Division of Environmental Health Services. The department would also like to thank other colleagues at the Missouri Hospital Association and Regional Health Commission for their input. Finally, the department would like to thank Andrew Hunter and his colleagues in the Bureau of Health Care Analysis and Data Dissemination at the Missouri Department of Health and Senior Services for their guidance in understanding the data. This report also benefited from the invaluable insights of important partners including Robert Fruend, Jr. and Angela Brown of the St. Louis Regional Health Commission, and Dr. Robert Poirier, Head of the Emergency Department at Barnes Jewish Hospital and Professor of Medicine at Washington University in St. Louis School of Medicine. Suggested citation Tutlam, NT, Kret, JE, Dalidowitz Dame, L, Wang, Y, DeClue, RW. Emergency Departments Visit Profile, St. Louis County, Missouri. Chronic Disease Epidemiology (CDE) program profile, no 4. St. Louis County, MO: Department of Public Health. Sept Chronic Disease Epidemiology Program The Chronic Disease Epidemiology (CDE) program is responsible for the analysis, interpretation, and presentation of health data related to chronic diseases and their risk factors. The CDE program supports the Saint Louis County Department of Public Health (DPH) by providing the following services: Developing study designs, questionnaires, and case definitions. Evaluating chronic disease programs. Locating or developing surveillance systems and analyzing epidemiologic data sets. Providing county, state, and national comparison data. Interpreting St. Louis County chronic disease and risk factor data. Conducting epidemiologic investigations and special studies of chronic diseases and chronic disease risk factors of public health importance. Monitoring St. Louis County chronic disease trends. Providing scientific advice and technical assistance to community groups and outside partners with respect to surveillance and other epidemiology data expertise. Publishing reports and web pages on chronic disease and risk factors. For more information about the CDE program, please send an e mail to: ChronicDisease.DOH@stlouisco.com

25 Emergency Department Visits Page 25 of 30 Appendix Appendix 1.1. Hospital emergency department visits per 1,000 population, St. Louis County, Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Rate 95% CI Count Missouri to to to to to ,215,461 St. Louis County to to to to to ,256 Age Group < 18 years to to to to to , years to to to to to , years to to to to to , years to to to to to , years and over Sex to to to to to ,748 Male to to to to to ,565 Female to to to to to ,089 Race/Ethnicity Asian to to to to to ,219 Black/African to to to to to ,433 American Hispanic or to to to to to ,143 Latino Multiple to to to to to ,771 White to to to to to ,741 Neighborhood Poverty Very High to to to to to ,610 High to to to to to ,984 Medium to to to to to ,822 Low to to to to to ,240 Geographic Area Central to to to to to ,499 Inner North to to to to to ,507 Outer North to to to to to ,102 South to to to to to ,609 West to to to to to ,939 Comparisons: Higher than the St. Louis County rate Lower than the St. Louis County rate Notes: Source: Missouri DHSS, Bureau of Health Care Analysis and Data Dissemination. Case Definition: Any visit to a hospital emergency department. Rates are age adjusted to the 2000 US population (not including Age Group rates). CI = Confidence Interval. Saint Louis County Department of Public Health October 18, 2017

26 Emergency Department Visits Page 26 of 30 Appendix 2.1. Number of visits by primary diagnosis at emergency department visit, classified by major disease category among adults over the age of 18 years: St. Louis County, Missouri, Major disease category ICD 9 CM code range Number of ED Visits Percent distribution All ED visits 1,062, Infectious and parasitic diseases , Neoplasm , Endocrine, nutritional, metabolic diseases, and immune disorders , Mental disorders , Diseases of the nervous system and sense organs , Diseases of the circulatory system , Diseases of the respiratory system , Diseases of the digestive system , Diseases of the genitourinary system , Diseases of the skin and subcutaneous tissue , Diseases of the musculoskeletal system and connective tissue , Symptoms, signs, and ill defined conditions , Injury and poisoning , Others* 59, *includes other diagnoses not included in these ICD 9 CM code ranges, those with supplementary classification, and those with missing primary diagnosis.

27 Emergency Department Visits Page 27 of 30 Appendix 2.2. Number of visits by primary diagnosis at emergency department visit, classified by major disease category for children less than 18 years: St. Louis County, Missouri, Major disease category ICD 9 CM code range Number of ED visits Percent distribution All ED visits 392, Infectious and parasitic diseases , Neoplasm Endocrine, nutritional, metabolic diseases, and immune disorders , Mental disorders , Diseases of the nervous system and sense organs , Diseases of the circulatory system Diseases of the respiratory system , Diseases of the digestive system , Diseases of the genitourinary system , Diseases of the skin and subcutaneous tissue , Diseases of the musculoskeletal system and connective tissue , Symptoms, signs, and ill defined conditions , Injury and poisoning , Others* 16, *includes other diagnoses not included in these ICD 9 CM code ranges, those with supplementary classification, and those with missing primary diagnosis.