Factors on Emergency Department Hospitalization Practices Keith - - PowerPoint PPT Presentation
The Impact of Patient Non-Clinical Factors on Emergency Department Hospitalization Practices Keith Kocher , Ryan McCammon, Kenneth Langa Department of Emergency Medicine Institute for Healthcare Policy and Innovation @kekocher University of
kkocher@umich.edu
ARM | 6.24.18
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Department of Emergency Medicine Institute for Healthcare Policy and Innovation University of Michigan
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ED hospitalization decisions may require balancing acute medical care needs with patient social support and functional capacity
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Health and Retirement Study linked to Medicare claims, 1999-2012
(median lag = 370 days; IQR = 183-569 days)
z
52,733 ED visits from 11,179 unique individuals
(43.7% hospitalized)
Excluded ED visits ending in ICU or transfers
(less discretionary)
By condition
(using clinical classification software, CCS, categories)
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Model 2
factors Constructed regression models Estimated differences in explanatory power of model = % change in C-statistic Model 1
support Model 4
status
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Table 1. Demographic and Clinical Factors Associated with Odds of Hospitalization from ED.
Demographic and Clinical Factors Adjusted Odds Ratio 95% CI Year of ED Visit [1998-2000, reference] 2001-2003 1.01 (0.95 – 1.07) 2004-2006 0.94 (0.89 – 1.00) 2007-2009 0.94 (0.88 – 0.99) 2010-2012 0.86 (0.81 – 0.92) Gender [male, reference] Female 0.82 (0.79 – 0.85) Age [65-74, reference] 75-84 1.14 (1.09 – 1.19) 85+ 1.31 (1.24 – 1.38) Race/ethnicity [non-Hispanic white, reference] Non-Hispanic black 0.87 (0.83 – 0.92) Hispanic/other 0.81 (0.75 – 0.87) Count Chronic Condition Warehouse (CCWs) [0-3, reference] 4-5 1.59 (1.51 – 1.68) 6-8 2.25 (2.14 – 2.37) 9+ 3.06 (2.88 – 3.24) Self-Reported Health [excellent/very good, reference] Good/fair/poor 1.07 (1.02 – 1.12)
Table 2. Socioeconomic Factors Associated with Odds of Hospitalization from ED.
Socioeconomic Status Adjusted Odds Ratio 95% CI Marital Status [Married/partnered, reference] Separated/divorced/never married 1.06 (0.98 – 1.14) Widowed 1.11 (1.05 – 1.18) Number of Household Residents [1, reference] 2 1.03 (0.97 – 1.09) 3+ 1.07 (1.01 – 1.14) Any Living Children [no, reference] Yes 0.91 (0.85 – 0.97) Any Living Siblings [no, reference] Yes 0.93 (0.89 – 0.97) Any Nearby Friends [no, reference] Yes 0.94 (0.91 – 0.98) Years of Schooling [12, reference] 0-11 0.92 (0.88 – 0.97) 13-15 0.94 (0.89 – 1.00) 16+ 0.94 (0.89 – 1.00) Household Assets [Lowest quartile, reference] Second lowest quartile 1.07 (1.02 – 1.13) Third lowest quartile 1.03 (0.97 – 1.09) Highest quartile 1.03 (0.97 – 1.10) Urban Residence [No, reference] Yes 1.37 (1.31 – 1.43)
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Table 3. Functional Status Factors Associated with Odds of Hospitalization from ED.
Functional Status Adjusted Odds Ratio 95% CI Activities of Daily Living Difficulties [none, reference] 1-2 0.97 (0.92 – 1.02) 3+ 1.03 (0.96 – 1.09) Mobility Difficulties [none, reference] 1-2 1.13 (1.07 – 1.19) 3+ 1.36 (1.27 – 1.45) Agility Difficulties [none, reference] 1-2 1.01 (0.95 – 1.06) 3+ 0.98 (0.92 – 1.05) Cognition [normal, reference] Cognitive impairment, no dementia (CIND) 1.02 (0.97 – 1.06) Dementia 1.07 (1.01 – 1.13)
4 questions related to large muscle strength: (1) walk several blocks, (2) walk one block, (3) climb
flights of stairs without resting 6 questions related to performing daily activities: (1) sit for two hours, (2) get up from a chair after sitting for long periods (3) lift or carry weights of more than 10 lbs, (4) stoop, kneel, or crouch, (5) pull or push a large object, (6) reach or extend their arms above the shoulder level
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Table 4. Stepwise Difference in Explanatory Power of the Model for Propensity of Hospitalization from the Emergency Department by Clinical Condition.
Clinical Condition
Model (C-Statistic) % Change C-Statistic
Demographics
Clinical Factors
Socioeconomic Support
Functional Status Model 2 to 4 Fracture of neck of femur (hip) 0.642 0.683 0.877 0.909 33.1% Allergic reactions 0.694 0.737 0.891 0.955 29.6% Other upper respiratory disease 0.614 0.675 0.794 0.815 20.7% Delirium, dementia, amnestic & cognitive disorders 0.617 0.623 0.719 0.736 18.1% Coronary atherosclerosis & other heart disease 0.583 0.597 0.687 0.704 17.9% Open wounds of extremities 0.657 0.681 0.769 0.791 16.2% Nausea and vomiting 0.620 0.651 0.735 0.754 15.8% Sprains and strains 0.637 0.668 0.719 0.765 14.5% Malaise and fatigue 0.636 0.680 0.742 0.777 14.3% Other upper respiratory infections 0.600 0.753 0.837 0.858 13.9% Open wounds of head; neck; and trunk 0.740 0.743 0.787 0.845 13.7% Intestinal obstruction without hernia 0.608 0.629 0.690 0.711 13.0% Headache; including migraine 0.649 0.694 0.767 0.779 12.2%
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Table 4. Stepwise Difference in Explanatory Power of the Model for Propensity of Hospitalization from the Emergency Department by Clinical Condition.
Clinical Condition
Model (C-Statistic) % Change C-Statistic
Demographics
Clinical Factors
Socioeconomic Support
Functional Status Model 2 to 4 Urinary tract infections 0.621 0.671 0.683 0.708 5.5% Asthma 0.618 0.722 0.747 0.761 5.4% Diverticulosis and diverticulitis 0.731 0.752 0.777 0.792 5.3% Gastrointestinal hemorrhage 0.599 0.656 0.690 0.690 5.2% Syncope 0.577 0.621 0.638 0.653 5.2% Residual codes; unclassified 0.668 0.680 0.700 0.715 5.1% Other lower respiratory disease 0.643 0.665 0.686 0.697 4.8% Fluid and electrolyte disorders 0.597 0.631 0.651 0.660 4.6% Skin and subcutaneous tissue infections 0.604 0.700 0.722 0.731 4.4% Other fractures 0.608 0.685 0.697 0.709 3.5% Cardiac dysrhythmias 0.585 0.638 0.653 0.659 3.3% Conditions associated with dizziness or vertigo 0.614 0.621 0.637 0.641 3.2% Superficial injury; contusion 0.613 0.690 0.695 0.711 3.0%
Administrative Claims Medicare
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Lag Time
Diagnoses
Discharge Admission
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