Potentially Preventable Emergency Room (ED) Visits Travis County - - PowerPoint PPT Presentation

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Potentially Preventable Emergency Room (ED) Visits Travis County - - PowerPoint PPT Presentation

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Potentially Preventable Emergency Room (ED) Visits Travis County July 15, 2013 0 Integrated Care Collaboration (ICC) Non-profit alliance of health care safety-net providers in Central Texas (Austin area) Multi-hospital systems

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July 15, 2013

Potentially Preventable Emergency Room (ED) Visits Travis County

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Integrated Care Collaboration (ICC)

  • Non-profit alliance of health care safety-net providers in Central Texas

(Austin area)

  • Multi-hospital systems
  • Public and private clinics
  • Federally qualified health centers
  • City public health clinics
  • Maintains a fully operational Health Information Exchange (HIE) system
  • Database called ICare

ICare Data, May 2012 - April 2013

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Methodology/Definitions

  • ICare Only Data Source used in this study
  • Timeframe: May 2012 – April 2013
  • Patient’s County of Residence Travis
  • ICare patients aged 18-64 years
  • At this time 65+ excluded due to lack of Medicare data in ICare

However, plans in process to add this payer

  • Chronic and Behavioral Health Dx are defined by the Healthcare Costs and

Utilization Project (HCUP) Clinical Classifications Software for ICD-9-CM http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp

  • Codes related to tobacco use have been excluded as BH Dx

ICare Data, May 2012 - April 2013

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Methodology/Definitions

  • There are two types of Behavioral Health classifications in the analysis
  • BH Patient: Patients are classified as BH patients if they had a BH

diagnosis (as defined by HCUP) at any clinic, ED, IP, or OP encounter during the timeframe

  • BH-Related ED Encounter/Visit: BH encounters are classified as ED

encounters in which a BH diagnosis (as defined by HCUP) was assigned at the encounter in any position. To be classified a BH-Related ED encounter, the BH diagnosis did not have to be the primary diagnosis

  • The list of ICD-9 codes defined by HCUP as Mental Illness is more

inclusive than the list of ICD-9 codes classified by the NYU algorithm as ‘Mental Health Related’. Because we used HCUP to define these groups and we looked at more than just the primary diagnosis, there are more ED encounters identified as BH-Related then are identified as Mental Health Related by the NYU algorithm

ICare Data, May 2012 - April 2013

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Methodology/Definitions

  • Definitions:
  • Medical Home: 2 consecutive clinic visits to the same organization in 18

months

  • Clinic Non-User: ED patients with no clinic visit within timeframe
  • Clinic User: ED patients with a clinic visit
  • Payor Grouping

Payor Plan Name Payor Plan Name Seton Charity BFAP

  • St. David's Charity

CHIP County Indigent Central Health MAP Other County Jail CSHCN Travis County Jail Medicaid FFS Medicare Medicaid MC Medicare MC Seton Pending Assistance Other/Unknown Edgar B Davis Self Pay Project Access Seton CCHC SFS SSI Pending Seton Care Plus TX Other Seton Musicians Seton Pending Assistance Seton Self Pay VA

  • St. David's Self Pay

Workers Comp Charity Medicaid Self Pay Other

ICare Data, May 2012 - April 2013

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Key Findings

  • 57.3% of visits for the time period were potentially preventable
  • Patients with Behavioral Health Dx at any encounter are less likely

to have a potentially preventable ED visit

  • Behavioral Health or Chronic Dx at ED encounter less likely to be a

potentially preventable ED visit

  • The ED rate among Behavioral Health patients is 1.67 times greater

than the ED rate among non-Behavioral Health patients

  • 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

ICare Data, May 2012 - April 2013

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Facts

  • Study
  • 55,549 Unique Patients
  • 99,591 ED Encounters
  • 57,105 or 57.3% Potentially Preventable ED visits
  • 37,811 ED Encounters for Clinic Users during timeframe
  • 30,033 ED Encounters for active Medical Home Patients

ICare Data, May 2012 - April 2013

Encounters % Encounters Total ED Encounters 99,591 Potentially Preventable 57,105 57.3% Non-Emergent 29,630 29.8% Emergent, Primary Care Treatable 23,650 23.7% Emergent, ED Care Needed, Preventable/ Avoidable 3,825 3.8% Emergent, ED Care Needed, Not Preventable/ Avoidable 11,960 12.0% Injury 15,705 15.8% Mental Health Related 2,363 2.4% Alcohol Related 2,021 2.0% Drug Related (excluding alcohol) 257 0.3% Not in a Special Category, and Not Classified 10,181 10.2%

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ED Encounter Demographics - Age

ICare Data, May 2012 - April 2013

24,019 23,909 7,621 43,757 42,976 12,858 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 20,000 40,000 18-30 Years 31-50 Years 51-64 Years Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

43.2% 43.0% 13.7% Unique Patients 18-30 Years 31-50 Years 51-64 Years 43.9% 43.2% 12.9% ED Encounters 18-30 Years 31-50 Years 51-64 Years

  • Age ranges of patients in the study are predominantly split between the 18-30 and 30-50

ranges (each being about 43% of all patients)

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ED Encounter Demographics - Gender

ICare Data, May 2012 - April 2013

30,430 25,119 57,376 42,215 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 20,000 40,000 60,000 Female Male Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

54.8% 45.2% Unique Patients Female Male 57.6% 42.4% ED Encounters Female Male

  • Female patients have the

highest rate of ED encounters per patient

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ED Encounter Demographics – Race/Ethnicity

ICare Data, May 2012 - April 2013

26,720 19,805 6,587 2,437 51,058 33,355 11,739 3,439 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 10,000 20,000 30,000 40,000 50,000 60,000 Hispanic White Black Other Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

11.9% 48.1% 4.4% 35.7% Unique Patients Black Hispanic Other White 11.8% 51.3% 3.5% 33.5% ED Encounters Black Hispanic Other White

  • Hispanic patients have the

highest rate of ED encounters per patient

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ED Encounter Demographics – Behavioral Health

ICare Data, May 2012 - April 2013

12,540 43,009 32,549 67,042 0.00 0.50 1.00 1.50 2.00 2.50 3.00 20,000 40,000 60,000 80,000 BH - Yes BH- No Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

22.6% 77.4% Unique Patients BH - Yes BH- No 32.7% 67.3% ED Encounters BH - Yes BH- No

  • BH Patient: Patients are classified as BH patients if they had a BH diagnosis (as

defined by HCUP) at any clinic, ED, IP, or OP encounter during the timeframe

  • The ED rate among Behavioral Health patients is 1.67 times greater than the ED

rate among non-Behavioral Health patients

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Top 5 Frequent Primary Diagnosis Codes for ED Visit

ICare Data, May 2012 - April 2013

  • Abdominal Pain and Pain in

Limb are frequent primary diagnoses in all age groups

648.93 OT CURRENT COND ANTEPARTUM 789.09 ABDOM PAIN OT/MULTI SITE 784.0 HEADACHE 789 ABDOM PAIN UNSP SITE 729.5 PAIN IN LIMB 789.09 ABDOM PAIN OT/MULTI SITE 784.0 HEADACHE 729.5 PAIN IN LIMB 786.2 COUGH 724.2 LUMBAGO 729.5 PAIN IN LIMB 789.09 ABDOM PAIN OT/MULTI SITE 786.2 COUGH 784.0 HEADACHE 786.5 UNSPECIFIED CHEST PAIN Age 51-64 Age 18-30 Age 31-50

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ED Encounters by Day and Time of Week

  • ED visits peak daily between 11:00 am and noon
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ED Encounter Demographics # ED Visits

  • Clinic Hours defined as 8am – 6pm

ICare Data, May 2012 - April 2013

Encounters Percent Encounters Percent TOTAL 46,272 100.0 9,277 100 Age 18-30 Years 20,071 43.4 3,948 42.6 31-50 Years 19,818 42.8 4,091 44.1 51-64 Years 6,383 13.8 1,238 13.3 Race/Ethnicity White 17,062 36.9 2,743 29.6 Black 5,411 11.7 1,176 12.7 Hispanic 21,581 46.6 5,139 55.4 Other 2,218 4.8 219 2.4 1 2 3 4 5 OT CURRENT COND ANTEPARTUM (648.93) ABDOM PAIN UNSP SITE (789.00) COUGH (486.2) COUGH (486.2) ABDOM PAIN OT/MULTI SITE (489.09) HEADACHE (784.0) PAIN IN LIMB (729.5) PAIN IN LIMB (729.5) HEADACHE (784.0) ABDOM PAIN OT/MULTI SITE (489.09) Patients w/ 1-2 ED Visits Patients w/ 3+ ED Visits 5 Most Common Primary Diagnoses

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ED Encounter Demographic Summary

  • Age ranges of patients in the study are predominantly split

between the 18-30 and 30-50 ranges (each being about 43%

  • f all patients)
  • Abdomen Pain and Pain in Limb frequent primary diagnosis in

all age groups

  • 55% Female, while overall ICare 55.0%
  • 48.1% Hispanic, while overall ICare 42.7%
  • Hispanic patients have the highest rate of ED encounters per

patient

  • The ED rate among Behavioral Health patients is 1.67 times

greater than the ED rate among non-Behavioral Health patients

  • Behavioral Health patients accounted for 22.6% of patients

and 32.7% of encounters

ICare Data, May 2012 - April 2013

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Patient Proximity to Nearest Facility

  • Only hospitals and clinics

that submit data to the ICC were included in distance calculations

  • Includes Travis County

residents whose exact address within Travis County was able to be geocoded

  • Distance was calculated to

the nearest Family Practice clinic

  • Dell Children's Hospital was

excluded from distance calculations

ICare Data, May 2012 - April 2013

  • Distance to facility does not seem to be a factor

Encounters Percent Encounters Percent TOTAL 14,834 100.0 29,796 100.0 Nearest Facility Clinic 13,343 89.9 25,373 85.2 Hospital 1,491 10.1 4,423 14.8 Distance to Clinic3 <1 mi 6,408 43.2 11,723 39.3 1-1.99 mi 4,944 33.3 9,800 32.9 2-4.99 mi 2876 19.4 6794 22.8 5-9.99 mi 501 3.4 1247 4.2 10+ mi 105 0.7 232 0.8 Distance to Hospital4 <1 mi 1,184 8.0 2,823 9.5 1-1.99 mi 2,290 15.4 4,948 16.6 2-4.99 mi 9,065 61.1 17,462 58.6 5-9.99 mi 1,861 12.5 3,664 12.3 10+ mi 434 2.9 899 3.0 Clinic User Clinic Non-User

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Patient Proximity to Nearest Facility

  • Only hospitals and clinics that submit data to the ICC were included in

distance calculations

  • Includes Travis County residents whose exact address within Travis

County was able to be geocoded

  • Distance was calculated to the nearest Family Practice clinic
  • Dell Children's Hospital was excluded from distance calculations

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 All Adults 3.35 5.41 35.1 95.5 Day/Time Weekday During Clinic Hours 3.38 5.45 34.6 95.95 Weekday During Non-Clinic Hours 3.33 5.34 35.65 95.03 Weekend 3.34 5.45 34.94 95.49

ICare Data, May 2012 - April 2013

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Patients Living >5 Miles from a Clinic

ICare Data, May 2012 - April 2013

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Patients with Clinic Visits

ICare Data, May 2012 - April 2013

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Patients with No Clinic Visits

ICare Data, May 2012 - April 2013

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Behavioral Health Patients

ICare Data, May 2012 - April 2013

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NYU Algorithm

ICare Data, May 2012 - April 2013 Source: New York University ED Algorithm, available at http://wagner.nyu.edu

  • 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

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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

ICare Data, May 2012 - April 2013 Source: New York University ED Algorithm, available at http://wagner.nyu.edu

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NYU Algorithm Category Distribution

ICare Data, May 2012 - April 2013 Source: New York University ED Algorithm, available at http://wagner.nyu.edu

  • Top 10 most frequent primary diagnosis codes for ED visits:

ICD-9 Code Diagnosis Non- Emergent Emergent, Primary Care Treatable Emergent, ED Care Needed, Preventable/ Avoidable Emergent, ED Care Needed, Not Preventable/ Avoidable Injury Mental Health Related Alcohol Related Drug Related (excluding alcohol) Not in a Special Category, and Not Classified 789.09 ABDOM PAIN OT/MULTI SITE 0.0% 67.0% 0.0% 33.0% 0.0% 0.0% 0.0% 0.0% 0.0% 784.0 HEADACHE 77.9% 9.1% 0.0% 13.0% 0.0% 0.0% 0.0% 0.0% 0.0% 729.5 PAIN IN LIMB 70.8% 16.7% 0.0% 12.5% 0.0% 0.0% 0.0% 0.0% 0.0% 786.2 COUGH 64.7% 23.5% 0.0% 11.8% 0.0% 0.0% 0.0% 0.0% 0.0% 789.00 ABDOM PAIN UNSP SITE 0.0% 67.0% 0.0% 33.0% 0.0% 0.0% 0.0% 0.0% 0.0% 724.2 LUMBAGO 73.6% 15.3% 0.0% 11.1% 0.0% 0.0% 0.0% 0.0% 0.0% 525.9 DENTAL DISORDER UNSPEC 89.7% 10.3% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 648.93 OT CURRENT COND ANTEPARTU 100.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 786.59 OTHER CHEST PAIN 0.0% 61.1% 0.0% 38.9% 0.0% 0.0% 0.0% 0.0% 0.0% 786.50 UNSPECIFIED CHEST PAIN 0.0% 32.4% 0.0% 67.6% 0.0% 0.0% 0.0% 0.0% 0.0%

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Potentially Preventable ED Visits by Group

Potentially Preventable 57.3% Emergent, ED Care Needed, Not Preventable/ Avoidable 12.0% Injury 15.8% Mental Health Related 2.4% Alcohol Related 2.0% Drug Related (excluding alcohol) 0.3% Not in a Special Category, and Not Classified 10.2%

Non- Emergent 51.9% Emergent, Primary Care Treatable 41.4% Emergent, ED Care Needed, Preventable/ Avoidable 6.7%

  • 57.3% or 57,105 of all ED Visits

were Potentially Preventable

ICare Data, May 2012 - April 2013 Source: New York University ED Algorithm, available at http://wagner.nyu.edu

Potentially Preventable

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Potentially Preventable ED Visits by Behavioral Health

Potentially Preventable 61.2% Emergent, ED Care Needed, Not Preventable / Avoidable 12.2% Injury 16.3% Mental Health Related 0.0% Alcohol Related 0.0% Drug Related (excluding alcohol) 0.0% Not in a Special Category, and Not Classified 10.3%

  • BH-Related ED Encounter/Visit: BH encounters are classified as ED encounters in which a

BH diagnosis (as defined by HCUP) was assigned at the encounter in any position. To be classified a BH-Related ED encounter, the BH diagnosis did not have to be the primary diagnosis

  • 61.2% of non-Behavioral Health ED Visits were Potentially Preventable, while 26% of

Behavioral Health ED Visits were Potentially Preventable

May 2012 - April 2013 Source: New York University ED Algorithm, available at http://wagner.nyu.edu

Non Behavioral Health Visits Potentially Preventable 26.0% Emergent, ED Care Needed, Not Preventable / Avoidable 10.6% Injury 11.4% Mental Health Related 21.4% Alcohol Related 18.1% Drug Related (excluding alcohol) 2.4% Not in a Special Category, and Not Classified 10.1% Behavioral Health Visits

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% Potentially Preventable ED Visits by Type

ICare Data, May 2012 - April 2013

57.3% Overall

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Potentially Preventable Rate of ED Visits by Type

ICare Data, May 2012 - April 2013

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% Potentially Preventable by Visit Type

28.7% 31.2% 32.0% 31.3% 23.0% 24.0% 26.0% 24.9% 4.0% 3.7% 3.9% 3.5% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% No clinic visit 1 clinic visit 2 clinic visits 3+ clinic visits Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

By Number of Clinic Visits

ICare Data, May 2012 - April 2013

57.3% Overall

58.9% 61.8% 59.7%

  • Patients with 2 visits to a clinic have a higher rate of preventable encounters and the highest

percent of Non-Emergent encounters

55.8%

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% Potentially Preventable by Visit Type

28.1% 30.1% 31.0% 23.3% 24.3% 23.9% 3.2% 4.0% 4.3% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 1 ED visit 2 ED visits 3+ ED Visits Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

By Number of ED Visits

ICare Data, May 2012 - April 2013

57.3% Overall

54.5% 58.4% 59.2%

  • Patients with 3+ visits to the ED have a higher percent of preventable encounters with highest

percent in Non-Emergent

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% Potentially Preventable by ED Visits

31.9% 25.4% 25.0% 21.2% 4.0% 3.6% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% BH No BH Yes Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

By Behavioral Health Patient Status

ICare Data, May 2012 - April 2013

57.3% Overall

60.8% 50.1%

  • Patients are classified as Behavioral Health patients if they had a Behavioral Health diagnosis

at any clinic, ED, IP, or OP encounter during the timeframe

  • The ED visits among Behavioral Health patients are less likely to be potentially preventable as

compared to non-Behavioral Health patients

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% Potentially Preventable ED Visits by Payor Mix

22.6% 20.5% 25.7% 38.8% 45.3% 29.2% 20.1% 24.1% 14.0% 16.7% 7.7% 30.0% 1.8% 2.3% 1.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% TOTAL Clinic Non-User Clinic User Other County Indigent Charity Self Pay and SFS Medicaid

ICare Data, May 2012 - April 2013 SFS– Sliding Fee Scale *Payor Mix at ED Encounter

  • 45.3% of all ED encounters among Clinic Non-Users were Self Pay compared to 29.2%

among Clinic Users

  • 30% of all ED encounters among Clinic Users were paid by County Indigent Program

compared to only 7.7% among Clinic Non-Users

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% Potentially Preventable ED Visits by Payor Mix

34.3% 38.6% 29.6% 24.5% 34.4% 24.7% 25.3% 23.6% 23.4% 14.2% 2.1% 2.1% 4.7% 4.9% 1.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% Charity County Indigent Medicaid Self Pay and SFS Other Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

Combined Clinic Users and Non Users

ICare Data, May 2012 - April 2013 *Payor Mix at ED encounter

  • 66.1% of all ED encounters paid by a County Indigent Program were potentially preventable,

which is nearly 25.1% higher than the Self Pay/SFS category, where only 52.8% of all ED encounters were potentially preventable

57.3% Overall

61.% 66.1% 57.9% 52.8% 49.7%

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Potentially Preventable ED Visits

26.0% 61.2% 29.2% 60.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 BH Yes BH No Chronic Yes Chronic No Total Encounter Preventable Encounters Percent

  • BH-Related ED Encounter/Visit: BH encounters are classified as ED encounters in which a

BH diagnosis (as defined by HCUP) was assigned at the encounter in any position. To be classified a BH-Related ED encounter, the BH diagnosis did not have to be the primary diagnosis

  • Of the 10,933 Behavioral Health Dx encounters, 4,551 or 41.6% had Behavioral Health as Primary Dx
  • Less likely to have a potentially preventable ED visit if there is a Behavioral Health Dx
  • Chronic Dx Primary at the ED visit
  • Less likely to have a potentially preventable ED visit if there is a Chronic Dx

Behavioral Health and Chronic Dx

ICare Data, May 2012 - April 2013

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Behavioral Health ED Encounters – Frequent Diagnoses

ICare Data, May 2012 - April 2013

Diagnoses Encounters Percent Total ED Encounters w/ Behavioral Health Diagnosis 10,933 100.0 Primary Behavioral Health Diagnosis 4,551 41.6 Nondependent Drug Abuse 1,602 35.2 Neurotic Disorders 1,027 22.6 Depressive Disorder Not Elsewhere Classified 384 8.4 Alcohol Dependence Syndrome 317 7.0 Other Nonorganic Psychoses 261 5.7 Affective Psychoses 255 5.6 Schizophrenic Disorders 187 4.1 Alcohol-Induced Mental Disorders 133 2.9 Special Symptom Not Elsewhere Classified 120 2.6 Drug Psychoses 89 2.0

  • The table shows that there were 10,933 ED encounters with a

Behavioral Health Dx in any position. Of those ED encounters, 41.6% had a primary Behavioral Health Dx, as defined by HCUP