Potentially Preventable Emergency Room (ED) Visits. Updated May 22, 2013

Transcription

1 Potentially Preventable Emergency Room (ED) Visits Updated May 22,

2 Methodology/Definitions Timeframe: March 2012 February 2013 Patient s County of Residence: Bastrop, Burnet, Caldwell, Hays, Travis, Williamson and Other < 65 in age Potentially Preventable ED Visits Non-Emergent Care not required within 12 hours Emergent, Primary Care Treatable Required treatment within 12 hours, but could have been in a primary care setting Emergent, ED Care Needed, Preventable/Avoidable Required treatment within 12 hours, but the urgency of the condition could have been avoided with better primary care Potentially Preventable ED by Clinic User and Clinic Non-User Clinic Non-User: ED patients with no clinic visit, within timeframe Clinic User: ED patients with a clinic visit Patients are classified as Behavioral Health (BH) patients if they had a BH diagnosis at any clinic, ED, IP or OP encounter during the timeframe 1

3 Facts ICare 575,395 Total Unique Patients 3,179,156 Total Encounters 268,367 Unique ED Patients 597,015 ED Encounters Study 135,788 Unique Patients 241,000 ED Encounters 141,822 or 58.8% Potentially Preventable ED Visits 83,929 ED Encounters with Clinic User During Timeframe 67,513 ED Encounters with Medical Home at ED Encounter 2

4 Unique Patients/ED Encounters Rate Demographics - Age 85,000 81, Unique Patients 71,247 67, % 65, % 0-17 Years 49, % Years Years 45,000 37,778 36, Years % 25,000 19, ED Encounters 11, % 5, % 0-17 Years 0-17 Years Years Years Years % Years Years -15, Years Unique Patients ED Encounters Rate 29.6% Age ranges of patients in the ICare system are predominantly split between the 0-18 and ranges (each being about 39%-41% of all patients), followed by the range (about 17% of patients). There is only a small number of patients in ICare over 65 years old (4% overall) 3

5 Top 5 Frequent Primary Diagnosis Codes for ED Visit Headache and/or cough frequent primary diagnosis in all age groups Dental Disorder 0-17, 102 nd 18-30, 5 th 31-50, 7 th 51-64, 18th Age FEVER UNSPECIFIED COUGH VOMITING ALONE ACUTE URI UNSPEC NONSPECIF SKIN ERUPT OT Age OT CURRENT COND ANTEPARTUM ABDOM PAIN OT/MULTI SITE 784 HEADACHE 789 ABDOM PAIN UNSP SITE DENTAL DISORDER UNSPEC Age ABDOM PAIN OT/MULTI SITE 784 HEADACHE PAIN IN LIMB COUGH LUMBAGO Age PAIN IN LIMB ABDOM PAIN OT/MULTI SITE UNSPECIFIED CHEST PAIN 784 HEADACHE COUGH 4

6 Unique Patients/ED Encounters Rate Demographics - Gender 150, Unique Patients 133, , , % 52.9% Female Male 90, ,778 63, ED Encounters 60, % Female 30, % Male Female Male 0.0 Unique Patients ED Encounters Rate 5

7 Unique Patients/ED Encounters Rate Demographics Race/Ethnicity 140, Unique Patients 120, , % 9.8% Black Hispanic 100,000 80,000 86, % 47.2% Other White 60,000 64,045 52, ED Encounters 9.7% 40, % Black Hispanic 20,000 13,339 23,482 6,185 8, % 50.7% Other White 0 Hispanic White Black Other 0.0 Unique Patients ED Encounters Rate 6

8 Unique Patients/ED Encounters Demographics - County 180, , , , % Unique Patients 4.2% 0.5% 3.1% 6.0% 0.7% Bastrop Burnet Caldwell Hays Other 96,360 Travis 90, % Williamson 60,000 30, ,510 19,720 13,350 9,341 7,523 8,140 5,667 2,143 4, % ED Encounters 3.9% 0.4% 3.1% 5.5% 0.9% Bastrop Burnet Caldwell Hays Other Travis Unique Patients ED Encounters 72.3% Williamson 7

9 Unique Patients/ED Encounters Rate Demographics Behavioral Health 180, , Unique Patients 16.1% 150, , , BH - Yes BH- No 90, % 60,000 57, ED Encounters 30,000 21, % BH - Yes 0 BH - Yes BH- No 0.00 BH- No Unique Patients ED Encounters Rate 76.1% Patients are classified as BH patients if they had a BH diagnosis at any clinic, ED, IP, or OP encounter during the timeframe The ED rate among BH patients is 1.64 times greater than the ED rate among non-bh patients 8

10 Demographic Summary 0-17 age group had the largest number of unique patients and encounters, while age group had the highest rate of encounters per person Headache and/or cough frequent primary diagnosis in all age groups 52.9% Female, while overall ICare 55.0% 47.2% Hispanic, while overall ICare 42.7% BH patients accounted for 16.1% of patients and 23.9% of encounters 9

11 Patient Location to Nearest Facility Clinic User Clinic Non-User Unique Unique Patients Percent Patients Percent TOTAL 31, , Nearest Facility Clinic 26, , Hospital 5, , Distance to Clinic 3 <1 mi 11, , mi 9, , mi 8, , mi 1, , mi , Distance to Hospital 4 <1 mi 2, , mi 5, , mi 18, , mi 3, , mi 1, , Only hospitals and clinics that submit data to the ICC were included in distance calculations Includes Travis and Williamson County residents whose exact address were able to be geocoded 3 For patients under age 18, the distance was calculated to the nearest Family Practice or Pediatric clinic. For adults aged 18+, the distance was calculated to the nearest Family Practice clinic 4 For adult patients, Dell Children's Hospital was excluded from distance calculations Distance to facility does not seem to be a factor 10

12 Patient Location to Nearest Facility Average Distance to Nearest Hospital Average Distance to Treatment Hospital Percent Receiving Treatment at Nearest Hospital Percent Living Closer to a Clinic than Treatment Hospital Age Group Children % 93.4% Adults % 89.4% Day/Time Weekday During Clinic Hours % 90.9% Weekday During Non-Clinic Hours % 90.6% Weekend % 90.9% Only hospitals and clinics that submit data to the ICC were included in distance calculations. Includes Travis and Williamson County residents whose exact address was able to be geocoded. For patients under age 18, the distance was calculated to the nearest Family Practice or Pediatric clinic. For adults aged 18+, the distance was calculated to the nearest Family Practice clinic. For adult patients, Dell Children's Hospital was excluded from distance calculations. 11

13 Zip Codes with 50+ Patients >5 Miles from Clinic 90.6% of patients live within 5 miles of a clinic, while 64.8% live within 2 miles 83.8% of patients live within 5 miles of a hospital, while 25.8% live within 2 miles 12

14 Patients with Clinic Visits Patients with clinic visits tend to live in or near Central Austin 13

15 Patients with No Clinic Visits Patients with no clinic visits tend to live in SE and Central Austin 14

16 BH Patients BH patients tend to live in or near Central Austin as well as East of I35 15

17 NYU Algorithm Developed by the NYU Center for Health and Public Service Research to help classify ED utilization. Developed with the advice of a panel of ED and primary care physicians Based on an examination of a sample of almost 6,000 full ED records (1994 & 1999) Abstracted data included the initial complaint, presenting symptoms, vital signs, medical history, age, gender, diagnoses, procedures performed, and resources used in the ED. Source: New York University ED Algorithm, available at 16

18 NYU Algorithm Non-Emergent - Immediate medical care was not required within 12 hours; Emergent/Primary Care Treatable - Treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation, and no procedures were performed or resources used that are not available in a primary care setting Emergent - ED Care Needed - Preventable/Avoidable - Emergency department care was required, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been received during the episode of illness Emergent - ED Care Needed - Not Preventable/Avoidable - Emergency department care was required and ambulatory care treatment could not have prevented the condition Source: New York University ED Algorithm, available at 17

19 NYU Algorithm Category Distribution Top 10 most frequent primary diagnosis codes for ED visits. ICD-9 Code Emergent, Primary Care Treatable Emergent, ED Care Needed, Preventable/ Avoidable Emergent, ED Care Needed, Not Preventable/ Avoidable Mental Health Related Drug Related (excluding alcohol) Not in a Special Category, and Not Classified Diagnosis Non- Emergent Injury Alcohol Related FEVER UNSPECIFIED 43.1% 37.3% 0.0% 19.6% 0.0% 0.0% 0.0% 0.0% 0.0% COUGH 64.7% 23.5% 0.0% 11.8% 0.0% 0.0% 0.0% 0.0% 0.0% ABDOM PAIN OT/MULTI SITE 0.0% 67.0% 0.0% 33.0% 0.0% 0.0% 0.0% 0.0% 0.0% PAIN IN LIMB 70.8% 16.7% 0.0% 12.5% 0.0% 0.0% 0.0% 0.0% 0.0% VOMITING ALONE 58.8% 23.5% 0.0% 17.6% 0.0% 0.0% 0.0% 0.0% 0.0% 784 HEADACHE 77.9% 9.1% 0.0% 13.0% 0.0% 0.0% 0.0% 0.0% 0.0% NONSPECIF SKIN ERUPT OT 75.4% 21.1% 0.0% 3.5% 0.0% 0.0% 0.0% 0.0% 0.0% 789 ABDOM PAIN UNSP SITE 0.0% 67.0% 0.0% 33.0% 0.0% 0.0% 0.0% 0.0% 0.0% ACUTE URI UNSPEC 0.0% 82.3% 17.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% HEAD INJURY UNSPEC 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0% Emergent, ICD-9 Code Diagnosis Non- Emergent Primary Care Treatable Avoidable Avoidable Injury FEVER UNSPECIFIED 43.1% 37.3% 0.0% 19.6% 0.0% COUGH 64.7% 23.5% 0.0% 11.8% 0.0% ABDOM PAIN OT/MULTI SITE 0.0% 67.0% 0.0% 33.0% 0.0% PAIN IN LIMB 70.8% 16.7% 0.0% 12.5% 0.0% VOMITING ALONE 58.8% 23.5% 0.0% 17.6% 0.0% 784 HEADACHE 77.9% 9.1% 0.0% 13.0% 0.0% Source: New York University ED Algorithm, available at Emergent, ED Care Needed, Preventable/ Emergent, ED Care Needed, Not Preventable/ 18 M H R

20 Potentially Preventable ED Visits by Group Alcohol Related 1.2% Mental Health Related 1.6% Injury 16.7% Emergent, ED Care Needed, Not Preventable/ Avoidable 11.4% Drug Related (excluding alcohol) 0.2% Not in a Special Category, and Not Classified 10.1% Potentially Preventable 58.8% 58.8% or 141,822 of all ED Visits were Potentially Preventable Emergent, ED Care Needed, Preventable/ Avoidable 6.2% Emergent, Primary Care Treatable 41.3% Potentially Preventable Non- Emergent 52.5% Source: New York University ED Algorithm, available at 19

21 Potentially Preventable ED Visits by Group Non BH Patients BH Patients Alcohol Related 0.0% Mental Health Related 0.0% Injury 17.4% Emergent, ED Care Needed, Not Preventable / Avoidable 11.1% Drug Related (excluding alcohol) 0.0% Not in a Special Category, and Not Classified 9.9% Potentially Preventable 61.5% Alcohol Related 4.8% Mental Health Related 6.7% Injury 14.5% Drug Related (excluding alcohol) 0.7% Emergent, ED Care Needed, Not Preventable / Avoidable 12.0% Not in a Special Category, and Not Classified 10.8% Potentially Preventable 50.4% 61.5% of non-bh ED Visits were Potentially Preventable, while 50.4% of BH ED Visits were Potentially Preventable Source: New York University ED Algorithm, available at 20

22 % Potentially Preventable ED Visits by Type 58.8% Overall 21

23 % Potentially Preventable Rate of ED Visits by Type No Yes No Yes No Yes No BH Medical Home Clinic User Clinic Visit ED Visit 22

24 % Potentially Preventable by ED Visits By Number of ED Visit 60.0% 58.8% Overall 50.0% 55.6% 59.8% 61.2% 3.7% 4.1% 3.1% 40.0% 23.4% 24.8% 24.8% 30.0% 20.0% 10.0% 29.1% 31.3% 32.3% 0.0% 1 visit 2 visits 3+ Visits Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent Patients with 3+ visits to the ED have a higher rate of preventable encounters, with highest percent in Non-Emergent 23

25 % Potentially Preventable by ED Visits - Age 100.0% 8.8% 8.4% 90.0% By Number of ED Visit 80.0% 26.6% 29.7% 70.0% 60.0% Years 50.0% 27.3% 30.3% Years Years 40.0% 0-17 Years 30.0% 20.0% 37.3% 31.5% 10.0% 0.0% 1-2 ED Visists 3+ ED Visits 24

26 % Potentially Preventable by ED Visits - Ethnicity 100.0% 5.0% 2.4% 90.0% By Number of ED Visit 80.0% 70.0% 45.4% 56.2% 60.0% Other 50.0% 40.0% 9.8% 9.9% Hispanic Black White 30.0% 20.0% 39.8% 31.5% 10.0% 0.0% 1-2 ED Visists 3+ ED Visits 25

27 % Potentially Preventable by ED Visits - Payor 100.0% 2.6% 6.9% 90.0% By Number of ED Visit 80.0% 26.8% 36.0% 70.0% 60.0% Other 50.0% 40.0% 39.1% 51.7% Self Pay and SFS Medicaid County Indigent Charity 30.0% 20.0% 10.0% 0.0% 7.1% 12.7% 11.0% 6.7% 1-2 ED Visists 3+ ED Visits 26

28 % Potentially Preventable by ED Visits 61.5% By BH Patient Status 60.0% 58.8% Overall 50.0% 40.0% 30.0% 3.7% 25.3% 50.4% 3.6% 21.2% 20.0% 10.0% 32.6% 25.6% 0.0% BH No BH Yes Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent The ED Visits among BH patients are less likely to be potentially preventable compared to non-bh patients 27

29 % ED Visits by Payor Mix 100.0% 90.0% 80.0% 70.0% 2.8% 3.3% 2.1% 3.3% 8.5% 17.8% 15.1% 13.8% 11.5% 60.0% 28.1% 30.9% 23.0% Other 50.0% 40.0% County Indigent Charity Self Pay and SFS 30.0% Medicaid 20.0% 46.7% 47.4% 45.6% 10.0% 0.0% TOTAL Clinic Non-User Clinic User 30.9% of all ED visits among Clinic Non-Users was Self Pay compared to 23.0% among Clinic Users 17.8% of all ED visits among Clinic Users was paid by County Indigent Program compared to only 3.3% among Clinic Non-Users SFS Sliding Fee Scale *Payor Mix at ED Encounter 28

30 % Potentially Preventable ED Visits by Payor Mix 70% 60% 58.8% Overall 50% 40% 30% 61.% 2% 25% 65.5% 2% 25% Combined Clinic User and Non User 62.4% 4% 26% 52% 53.1% 5% 23% 2% 19% Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable 20% 10% 34% 38% 33% 25% 32% Non-Emergent 0% Charity County Indigent Medicaid Self Pay and SFS Other 65.5% of all ED encounters paid by a County Indigent Program were potentially preventable, which is nearly 26% higher than the Self Pay/SFS category, where only 52% of all ED encounters were potentially preventable *Payor Mix at ED encounter 29

31 % Potentially Preventable ED Visits by Payor Mix* 70.0% Clinic Non User 60.0% 1.8% 2.2% 3.5% 58.8% 50.0% 24.4% 24.5% 25.5% 5.1% 1.6% Emergent, ED Care Needed, Preventable/ Avoidable 40.0% 30.0% 22.1% 18.5% 61.% 64.9% 62.5% 50.9% 51.5% Emergent, Primary Care Treatable Non-Emergent 20.0% 10.0% 34.6% 38.2% 33.5% 23.6% 31.4% 0.0% Charity County Indigent Medicaid Self Pay and SFS Other *Payor Mix at ED encounter 30

32 % Potentially Preventable ED Visits by Payor Mix* 70.0% Clinic User 2.1% 60.0% 2.4% 4.0% 1.2% 58.8% 50.0% 26.2% 25.6% 25.5% 4.3% 21.7% Emergent, ED Care Needed, Preventable/ Avoidable 40.0% 23.7% Emergent, Primary Care Treatable 30.0% 61.5% 65.7% 62.2% 54.8% 58.1% Non-Emergent 20.0% 10.0% 32.9% 37.9% 32.7% 26.8% 35.2% 0.0% Charity County Indigent Medicaid Self Pay and SFS Other *Payor Mix at ED encounter 31

33 Potentially Preventable ED Visits by BH 250,000 Total Encounter Preventable Encounters Percent 70.0% 200, % 53.9% 64.2% 59.5% 60.0% 50.0% 150, % 100, % 27.6% 30.0% 20.0% 50, % 0 All Yes All All No <18 Yes <18 <18 No Adult Yes Adult Adult No Yes No Yes No Yes No BH Dx at the ED visit in any position Of the 17,764 BH Dx encounters, 6,960 or 39.2% had BH as Primary Dx Less likely to have a potentially preventable ED visit if there is a BH DX 0.0% 32

34 BH ED Encounters Frequent Diagnoses Diagnoses Encounters Percent Total ED Encounters w/ BH Diagnosis 17, Primary BH Diagnosis 6, % Nondependent Drug Abuse 2, % Neurotic Disorders 1, % Depressive Disorder Not Elsewhere Classified % Alcohol Dependence Syndrome % Other Nonorganic Psychoses % Affective Psychoses % Schizophrenic Disorders % Special Symptom Not Elsewhere Classified % Alcohol-Induced Mental Disorders % Drug Psychoses % 33

35 Potentially Preventable ED Visits by Chronic Diagnosis 250, ,000 Total Encounter Preventable Encounters Percent 64.6% 60.5% 58.5% 70.0% 60.0% 50.0% 150, % 100, % 32.7% 30.0% 20.9% 20.0% 50, % 0 All Yes All All No <18 Yes <18 < 18 No Adult Yes Adult Adult No Yes No Yes No Yes No 0.0% Chronic Dx Primary at the ED visit Less likely to have a potentially preventable ED visit if there is a Chronic DX 34

36 Potentially Preventable ED Visits by Day of Week 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 Total Encounter Preventable Encounters Percent Sunday Monday Tuesday Wednesday Thursday Friday Saturday

37 Potentially Preventable ED Visits by Time of Day 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Total Encounter Preventable Encounters Percent 12:00 am - 5:59 am 6:00 am - 11:59 am 12:00 pm - 5:59 pm 6:00 pm - 11:59 pm

38 Potentially Preventable ED Visits Day and Time Age 100.0% 90.0% 9.6% 6.9% 8.2% 80.0% 70.0% 30.7% 26.5% 26.9% 60.0% Years 50.0% 40.0% 29.3% 30.3% 28.9% Years Years 0-17 Years 30.0% 20.0% 30.4% 36.3% 36.0% 10.0% 0.0% Clinic Hrs Non-Clinic Hrs Wk End 37

39 Potentially Preventable ED Visits Day and Time Ethnicity 100.0% 3.6% 3.7% 3.8% 90.0% 80.0% 70.0% 49.9% 52.0% 50.3% 60.0% Other 50.0% Hispanic Black 40.0% 10.3% 9.5% 9.3% White 30.0% 20.0% 36.2% 34.8% 36.6% 10.0% 0.0% Clinic Hrs Non-Clinic Hrs Wk End 38

40 Potentially Preventable ED Visits Day and Time Payor 100.0% 4.6% 4.8% 4.9% 90.0% 80.0% 32.2% 31.0% 30.7% 70.0% 60.0% 50.0% 40.0% 42.4% 46.4% 46.3% Other Self Pay and SFS Medicaid County Indigent Charity 30.0% 20.0% 10.0% 0.0% 11.7% 9.5% 9.6% 9.1% 8.4% 8.5% Clinic Hrs Non-Clinic Hrs Wk End 39

41 Conclusions 58.8% of visits for the time period were potentially preventable Patients with BH at any encounter less likely to have a potentially preventable ED visit BH or Chronic Dx at ED encounter less likely to be a potentially preventable ED visit Non Users of clinic have higher proportion of self pay in payor mix Distance to a clinic or hospital does not seem to be a factor 40