Emergency Department Presentation for Uncomplicated Acute Rhinosinusitis Is Associated With Poor Access to Healthcare

Transcription

1 The Laryngoscope VC 2015 The American Laryngological, Rhinological and Otological Society, Inc. Emergency Department Presentation for Uncomplicated Acute Rhinosinusitis Is Associated With Poor Access to Healthcare George A. Scangas, MD; Stacey L. Ishman, MD, MPH; Regan W. Bergmark, MD; Michael J. Cunningham, MD; Ahmad R. Sedaghat, MD, PhD Objectives/Hypothesis: Uncomplicated acute rhinosinusitis (ARS) is most appropriately managed in an outpatient clinic setting. Some ARS patients present to emergency departments (EDs) for care. We investigates factors associated with ARS presentation to EDs versus outpatient settings. Study Design: Cross-sectional study. Methods: A total of 17,122,551 pediatric and adult patient visits from the 2009 and 2010 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for ARS were identified. Patients with ARS complications were excluded. Univariate and multivariate associations identified demographic and socioeconomic characteristics of ARS patients independently associated with ED presentation. Temperature >100 F was used as a proxy for ARS severity. Results: Patients with Medicaid (odds ratio [OR] , P <.001) or no insurance (OR , P <.001) more likely presented to EDs when compared to patients with private insurance or Medicare. Independently, black patients (OR , P <.001) more likely presented to EDs when compared to white or Hispanic patients. No significant association was seen with metropolitan or socioeconomic status based upon the patients home zip code. Conclusions: Presentation of ARS patients to EDs is associated with health insurance type and patient race independent of socioeconomic status. Healthcare access appears to be a primary determinant of whether patients present to an ED or outpatient setting for this common health problem. The association between race and ED presentation suggests cultural underpinnings requiring further characterization. Reducing barriers to care, for example through broader health insurance coverage, may enhance access to outpatient care providers and decrease costs associated with unnecessary ED presentation. Key Words: Health policy, outcomes, cost effectiveness, clinical, allergy, rhinology. Level of Evidence: 4. Laryngoscope, 125: , 2015 INTRODUCTION Acute rhinosinusitis (ARS), defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting <4 weeks, typically begins as a viral upper respiratory infection that may become superimposed with a bacterial infection. 1 ARS is one of the most commonly treated conditions, with an estimated 20 million cases From the Department of Otolaryngology Head and Neck Surgery (G.A.S., R.W.B., A.R.S.), Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Department of Otology and Laryngology (G.A.S., R.W.B., M.J.C., A.R.S.), Harvard Medical School, Boston, Massachusetts; Division of Otolaryngology Head and Neck Surgery (S.L.I.) and Division of Pulmonary Medicine (S.L.I.), Cincinnati Children s Hospital Medical Center, Cincinnati, Ohio; Department of Otolaryngology Head & Neck Surgery (S.L.I.), University of Cincinnati, Cincinnati, Ohio; and Department of Otolaryngology and Communications Enhancement (M.J.C.), Boston Children s Hospital, Boston, Massachusetts. Editor s Note: This Manuscript was accepted for publication February 2, Presented as a poster at the American Rhinologic Society Meeting at the 60th Annual Meeting of the American Academy of Otolaryngology Head and Neck Surgery Foundation, Orlando, Florida, U.S.A., September 20 21, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ahmad R. Sedaghat, MD, PhD, Department of Otolaryngology Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles St., Boston, MA ahmad_sedaghat@meei.harvard.edu DOI: /lary occurring annually in the United States. 2 Owing in large part to its high incidence, ARS has a considerable economic impact on healthcare expenditures. In the United States, the direct costs of sinusitis management is estimated at $3 billion per year inclusive of initial medications and antibiotic treatment failures, ancillary tests and procedures, and outpatient and emergency department (ED) visits. 1,2 This figure does not account for decreased productivity from missed days of work or school, which adds significant indirect costs. Infrequent but potential ARS sequelae, such as orbital or intracranial infectious complications, further contribute to this economic burden. 3 Consensus guidelines have established criteria for the diagnosis and treatment of ARS. 1,4,5 The vast majority of ARS cases are uncomplicated and do not require emergent evaluation or treatment. Uncomplicated cases of ARS are most appropriately managed in an outpatient setting and are typically treated conservatively with observation or a brief course of antibiotics. Despite the usually benign nature of uncomplicated ARS, a significant fraction of patients present to the ED for evaluation. The reasons for such ED presentations are not entirely clear. ED evaluations are associated with higher cost in comparison to evaluations in alternative outpatient primary care settings. Previous work has shown ED 2253

2 presentations for nonurgent conditions may be a major source of excessive healthcare spending due not only to costs directly attributable to ED facility fees but also from additional site-related testing and treatment. 6,7 Because the incidence of uncomplicated ARS is high, the presentation of even a fraction of these patients to EDs represents a potentially significant avoidable healthcare expenditure, in addition to missed opportunities to promote longitudinal relationships with primary care physicians. 8,9 In this cross-sectional study, we investigated factors associated with the presentation of uncomplicated ARS to EDs versus other outpatient settings. MATERIALS AND METHODS Study Population The National Ambulatory Medical Care (NAMCS) and National Hospital Ambulatory Medical Care Surveys (NHAMCS) from 2009 and 2010 were screened for patients with ARS by searching for all patients with at least one International Classification of Diseases, Ninth Revision (ICD-9) code for acute sinusitis (461.0, 461.1, 461.2, 461.3, 461.8, and 461.9) assigned to any of the three diagnoses included in the databases. NAMCS is a national probability sample survey of patient visits to non federally employed, office-based physicians practicing direct patient care in the United States. NHAMCS is a national probability sample survey of patient visits to ambulatory care services in hospital-based offices or EDs in the United States. Both of these databases are maintained by the Centers for Disease Control and Prevention. The primary outcome measure for this study was dichotomously measured as patient presentation to either an ED or an outpatient clinic. Outpatient clinics were either hospital-based or office-based, for example, private solo or group practices, free standing clinic/urgicare centers, community health centers, mental health centers, non federal government clinics, family planning clinics, health maintenance organization, or other prepaid practices and faculty practice plans. Outpatient clinics staffed by federally employed physicians (for example affiliated with the Veterans Affairs or the military) were excluded. Excluded from analysis were patients with ICD-9 codes for ARS complications including preseptal or periorbital cellulitis (373.13), orbital cellulitis or abscess (376.0, , and ), intracranial complications of intracranial abscess (324.0), and cavernous sinus thrombosis (325.0). Patient Characteristics Patient characteristics of age, gender, and race were extracted in addition to the primary payer (i.e., insurance type) listed for the visit. A temperature greater than F was also recorded and used as an indicator of disease severity. Characteristics of the patients home zip code were extracted, including: 1) median income level for the zip code, 2) the percentage of individuals living below the poverty line in that zip code, and 3) metropolitan status of that zip code (as defined by criteria from the US Office of Management and Budget). Statistical Analysis All analysis was performed with the statistical software package R ( R Foundation for Statistical Computing, Vienna, Austria). Weighted associations between ED presentation and predictor variables were determined by logistic regression using the lrm() function from the Regression 2254 Modeling Strategies (rms) package. 10 Missing data were omitted. Quality control by confirming minimum numbers of data entries for each category as well as calculation of relative standard errors to ensure reliability of results, as recommended by the Centers for Disease Control and Prevention, was performed. Univariate logistic regression was performed for each predictor variable. Multivariate logistical analysis was performed using all predictor variables with P.100 in the univariate regression. In the multivariate model, significant predictors were identified via backward elimination, using a P value cutoff of Cross-validation was performed through bootstrapping of the dataset using the validate() function from the rms package over 100 iterations. For each variable retained in the final model, a P value and a log-odds ratio were calculated. P values <.05 were considered significant. RESULTS Demographic Characteristics of ARS Patients The NAMCS and NHAMCS included 17,122,551 pediatric and adult visits for uncomplicated ARS in 2009 and 2010 (Table I). Patients were on average 39.4 years old (standard deviation: 20.6 years) having a gender composition of 40.4% male and 59.6% female. There was a slight skew toward younger patients and females more so than males presenting to EDs. Racial differences were also observed in ED utilization. Whereas patients characterized as white represented 77.3% of all patients presenting to outpatient clinics for ARS, only 49.2% of patients presenting to EDs were white. In contrast, Hispanic and black patients represented 9.1% and 11.4% of patients, respectively, presenting to outpatient clinics but represented 12.0% and 36.2%, respectively, of patients presenting to EDs. Primary payer status was also noted to be differentially distributed between uncomplicated ARS patients presenting to outpatient clinics in comparison to EDs. Although the most frequent primary payer for uncomplicated ARS outpatient clinic visits was private insurance (74.6%), the most frequent primary payer for uncomplicated ARS ED visits was Medicaid (37.8%). The presence of an elevated temperature additionally suggested uncomplicated ARS severity may impact presentation to an ED. Specifically, an elevated temperature greater than F was present in 1.8% of patients presenting to outpatient clinics in contrast to 11.8% of patients presenting to EDs. With respect to where uncomplicated ARS patients live, differences were observed between those patients who presented to EDs in comparison to those who presented to outpatient clinics. Patients presenting to EDs tended to live in lower-income zip codes with greater levels of poverty. Of uncomplicated ARS patients presenting to EDs, 43.1% lived in zip codes within the lowest quartile of national income levels, and 29.6% lived in zip codes with a >20% poverty level. This was in contrast to uncomplicated ARS patients presenting to outpatient clinics, of whom only 14.6% lived in zip codes within the lowest quartile of national income levels, and 8.2% lived in zip codes with >20% poverty levels. Metropolitan status of uncomplicated ARS patients home zip codes were not very different between those presenting to EDs and outpatient clinics, although a higher proportion of

3 TABLE I. Clinicodemographic Characteristics of Patients With Acute Rhinosinusitis. All Office-Based Practice Emergency Department Patient characteristics No. of visits 17,122,551 16,131, ,849 Fraction of visits (%) Age, yr (SD) 39.4 (20.6) 39.8 (20.6) 33.0 (18.1) Gender, % female Temperature >100.0 F, % Race White Hispanic Black Other Primary payer Private Medicare Medicaid Self-pay Other Patient s home zip code characteristics Median income quartile, percentile Percent poverty <5% % 9.99% % 19.99% >20.00% Metropolitan status Large metropolitan Medium/small metropolitan Nonmetropolitan SD 5 standard deviation. uncomplicated ARS patients presenting to EDs were from nonmetropolitan areas compared to those presenting to outpatient clinics (23.8% vs. 11.7%, respectively). Clinical and Demographic Factors Associated With ARS Presentation to an ED Versus Outpatient Clinic Several patient-specific factors were found to be statistically associated with uncomplicated ARS presentation to an ED versus outpatient clinic on both univariate and multivariate analyses (Table II). Gender was not associated with site of presentation. Although lower age was associated with ED presentation on univariate analysis, this association was not significant on multivariate association. Race was significantly associated with ED presentation for uncomplicated ARS. More specifically, black patients (odds ratio [OR] , P <.001) were more likely to present to EDs for uncomplicated ARS in comparison to white patients. Insurance status was also significantly associated with ED presentation. Uncomplicated ARS patients with Medicaid (OR , P <.001) or self-pay status (OR , P <.001) were more likely to present to EDs compared to patients with private insurance. Interestingly, however, neither the median income level nor the poverty level of the patients home zip codes, which we utilized as surrogate markers for socioeconomic status, were significantly associated with ED presentation for uncomplicated ARS. DISCUSSION The management of uncomplicated ARS, a common affliction affecting millions of individuals annually, is well defined. 1,4,5 Such management is not emergent, even though sinonasal symptomatology may be inconvenient 2255

4 TABLE II. Clinicodemographic Factors Associated With Acute Rhinosinusitis Presentation to an Emergency Department Versus Outpatient Clinic. Univariate Odds Ratio* Univariate P Value Multivariate Odds Ratio* Multivariate P Value Patient characteristics Age, yr 0.98 ( ) Gender, female Temperature >100.0 F 7.51 ( ) < ( ).009 Race White Hispanic Black 5.74 ( ) < ( ) <.001 Other Primary payer Private Medicare Medicaid 7.98 ( ) < ( ) <.001 Self-pay ( ) < ( ) <.001 Other Patient s home zip code characteristics Median income quartile, percentile ( ) < ( ) ( ) <.001 Percent poverty.115 <5% % 9.99% % 19.99%.157 >20.00% 7.52 ( ) <.001 Metropolitan status.210 Large metropolitan 1.0 Medium/small metropolitan.854 Nonmetropolitan 2.30 ( ).030 *Odds ratios (ORs) for reference variables are represented as 1.0, and ORs that are not statistically different from 1.0 are represented with a dash ( ). and lead to lost productivity. ARS is a source of substantial healthcare costs attributable to physician visits, diagnostic imaging, medical treatment, and infrequently surgical interventions for acute orbital or intracranial complications. 11,12 By virtue of the high prevalence of ARS, the impact of even small unnecessary healthcare expenditures is proportionately magnified. As such, the identification and elimination of unnecessary healthcare costs related to ARS may have significant financial implications. Previous work has shown ED visits for nonurgent conditions are associated with increased expenditures due not only to higher directly billed facility fees and patient copayments but also to additional, potentially unnecessary, tests and treatments. 6 9,13 Our premise is the evaluation and management of uncomplicated ARS is most appropriately handled in an outpatient clinic, and ED visits for uncomplicated ARS contribute to unnecessary healthcare costs. This analysis of a comprehensive national database of outpatient clinic and ED visits for patients with ARS uncovers novel associations highlight ing healthcare access as well as cultural underpinnings for preferential ED usage in these patients. We found patients with Medicaid and self-pay/no insurance, historically associated with poor access to healthcare, were more likely to present to an ED for uncomplicated ARS. This observation was independent of our markers for socioeconomic status, which were not associated with ED presentation. Although lower socioeconomic status may have been intuitively expected to be associated with ED utilization, our results suggest health insurance status rather than wealth may be the primary determinant of access to primary care for uncomplicated ARS. This finding is also consistent with recent work assessing the outcomes of the Oregon Health Insurance Experiment, in which approximately 30,000 out of 90,000 low-income, uninsured individuals were randomly selected for the Oregon Health Plan, a Medicaid expansion program. 13 Despite previous arguments that health insurance such as Medicaid would decrease unnecessary ED presentations, the Oregon

5 Health Insurance Experiment found Medicaid coverage increased ED visits by 40% relative to individuals who did not receive Medicaid coverage, although the availability of primary care practitioners accepting Medicaid was not directly taken into account. 23 Most notably, the majority of ED visits for Medicaid-insured patients were for conditions deemed either primary care treatable or nonemergent. 23 Uncomplicated ARS is similarly a condition that is more suitably treated in an outpatient setting. Our finding that patients with Medicaid and selfpay insurance preferentially present to EDs for uncomplicated ARS, even after adjustment for socioeconomic factors, requires further investigation for the possible underlying reasons as well as targeted interventions. In contrast to individuals with private insurance, individuals with Medicaid or no insurance are more likely to have poorer baseline health, inadequate preventative and maintenance healthcare from a consistently accessible provider, and a greater inability to navigate the healthcare system In the United States, the percentage of physicians not accepting new Medicaid patients is up to twice the percentage of physicians not accepting new patients with private insurances. Higher Medicaid reimbursement rates have been found to correlate with increased acceptance rates for these patients. 28 There are also financial barriers for low-income patients and patients with certain types of insurance to access primary care. In addition to challenges with access, other barriers to outpatient primary care include a distrust of primary practitioners and the perception of superior care at an ED. 29 Future policies directed at reducing unnecessary ED visits should aim to increase access to and utilization of primary care physicians. There are many barriers to primary care including lack of education and counseling around appropriate use, financial barriers, challenges making appointments and lack of providers accepting certain types of insurance, such as Medicaid. Education of patients should include counseling with respect to perceptions and utilization of primary care facilities, because as healthcare coverage is expanded, it is plausible that newly insured or Medicaid patients may continue to present to the ED for care despite the availability of outpatient clinics. Increased access to primary care physicians may be created through health policy that provides greater incentives for treatment of Medicaid or uninsured patients, as well as by the establishment of primary care offices in underserved areas, outreach to underserved areas, and removing financial barriers to accessing primary care. Our data on the number of physician visits associated with just uncomplicated ARS during 2009 and 2010 suggest such interventions, if successful, could result in up to 500,000 fewer ED visits per year. Race was also found to be associated with ED presentation for uncomplicated ARS. Disparities in healthcare are well documented between racial groups for a wide range of measures including infant mortality, cardiovascular disease, cancer incidence, and overall mortality. 26,30 The reasons for these disparities are complex and mediated by socioeconomic inequalities impacting health, human behavior, and access to healthcare resources. 31 In the present study, black patients were found to be more likely to present to EDs for uncomplicated ARS independent of markers of socioeconomic status. At present, very little is known regarding the epidemiology of ARS as it relates to racial and ethnic minorities. Given the significant economic burden of ARS and the considerable quality-of-life declines seen in patients with sinusitis, 4,5 a significant burden of disease may exist in minority populations that remains underappreciated and underestimated. Alternatively, disparate access to outpatient clinics (e.g., living in areas with few primary care clinics) or general cultural preferences to utilize EDs cannot be excluded. These potential reasons for the association of race with ED presentation requires further characterization. The results of this study should be interpreted within the limitations imposed by the cross-sectional study design of the 2009 and 2010 NAMCS and the NHAMCS databases. We are constrained to the data contained within these databases. For example, one pertinent factor expectedly associated with ED presentation for ARS is severity of clinical presentation; patients who are more ill from ARS may be more likely to present to EDs. There is, however, no direct measure for ARS severity for example a validated ARS-specific symptoms survey filled out by patients in the NAMCS and NHAMCS that can be controlled for. We chose to use elevated temperature >100.0 F as an indirect measure of ARS severity, because fever has been previously described as a clinical sign for ARS necessitating antibiotic treatment. Consistent with our underlying assumption, we found a temperature >100.0 F was independently associated with ED presentation, although we recognize there is no assurance that elevated temperature is a consistent and reliable measure of ARS severity. Neither the NAMCS nor NHAMCS contain direct measures of socioeconomic status. We alternatively used proxies for socioeconomic statussuchasmedianincomeorpercentageofindividuals living below the poverty level within the patients zip codes. This limitation prevents more precise association between socioeconomic status and wealth with ED presentation of patients with uncomplicated ARS. Other factors, such as the relative geographic distribution or hours of operation for clinics in comparison to EDs, which may directly impact ED over outpatient clinic utilization, are not represented in these databases and could not be controlled for. CONCLUSION The presentation of uncomplicated ARS patients to EDs is associated with health insurance status and race independent of markers of socioeconomic status or disease severity. Health insurance status, likely a reflection of healthcare access, appears to be a primary determinant of whether patients present to an ED or an alternative primary care, outpatient setting for this common health problem. The association between race and ED presentation suggests cultural underpinnings or a racially disparate burden of disease requiring further 2257

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