Potentially Preventable Emergency Room (ED) Visits Updated May 22, - - PowerPoint PPT Presentation

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Potentially Preventable Emergency Room (ED) Visits Updated May 22, - - PowerPoint PPT Presentation

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Potentially Preventable Emergency Room (ED) Visits Updated May 22, 2013 0 Methodology/Definitions Timeframe: March 2012 February 2013 Patients County of Residence: Bastrop, Burnet, Caldwell, Hays, Travis, Williamson and Other

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Updated May 22, 2013

Potentially Preventable Emergency Room (ED) Visits

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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

March 2012-February 2013

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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

March 2012-February 2013

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Demographics - Age

March 2012-February 2013

49,348 37,778 36,801 11,851 81,823 71,247 67,998 19,942 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0

  • 15,000

5,000 25,000 45,000 65,000 85,000 0-17 Years 18-30 Years 31-50 Years 51-64 Years Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

36.3% 27.8% 27.1% 8.7% Unique Patients 0-17 Years 18-30 Years 31-50 Years 51-64 Years 34.0% 29.6% 28.2% 8.3% ED Encounters 0-17 Years 18-30 Years 31-50 Years 51-64 Years

  • Age ranges of patients in the ICare system are predominantly split between the 0-18 and 19-

44 ranges (each being about 39%-41% of all patients), followed by the 45-64 range (about 17% of patients). There is only a small number of patients in ICare over 65 years old (4% overall)

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Top 5 Frequent Primary Diagnosis Codes for ED Visit

March 2012-February 2013

780.6 FEVER UNSPECIFIED 786.2 COUGH 787.03 VOMITING ALONE 465.9 ACUTE URI UNSPEC 782.1 NONSPECIF SKIN ERUPT OT 648.93 OT CURRENT COND ANTEPARTUM 789.09 ABDOM PAIN OT/MULTI SITE 784 HEADACHE 789 ABDOM PAIN UNSP SITE 525.9 DENTAL DISORDER UNSPEC 789.09 ABDOM PAIN OT/MULTI SITE 784 HEADACHE 729.5 PAIN IN LIMB 786.2 COUGH 724.2 LUMBAGO 729.5 PAIN IN LIMB 789.09 ABDOM PAIN OT/MULTI SITE 786.5 UNSPECIFIED CHEST PAIN 784 HEADACHE 786.2 COUGH Age 51-64 Age 0-17 Age 18-30 Age 31-50

  • Headache and/or cough

frequent primary diagnosis in all age groups

  • Dental Disorder
  • 0-17, 102nd
  • 18-30, 5th
  • 31-50, 7th
  • 51-64, 18th
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Demographics - Gender

March 2012-February 2013

71,778 63,998 133,437 107,559 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 30,000 60,000 90,000 120,000 150,000 Female Male Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

52.9% 47.1% Unique Patients Female Male 55.4% 44.6% ED Encounters Female Male

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Demographics – Race/Ethnicity

March 2012-February 2013

64,045 52,209 13,339 6,185 122,243 86,425 23,482 8,860 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 80,000 100,000 120,000 140,000 Hispanic White Black Other Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

9.8% 47.2% 4.6% 38.5% Unique Patients Black Hispanic Other White 9.7% 50.7% 3.7% 35.9% ED Encounters Black Hispanic Other White

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Demographics - County

March 2012-February 2013

96,360 19,720 8,140 5,667 4,248 972 671 174,220 33,510 13,350 9,341 7,523 2,143 923 30,000 60,000 90,000 120,000 150,000 180,000 Unique Patients/ED Encounters

Unique Patients ED Encounters

4.2% 0.5% 3.1% 6.0% 0.7% 71.0% 14.5% Unique Patients Bastrop Burnet Caldwell Hays Other Travis Williamson 3.9% 0.4% 3.1% 5.5% 0.9% 72.3% 13.9% ED Encounters Bastrop Burnet Caldwell Hays Other Travis Williamson

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Demographics – Behavioral Health

March 2012-February 2013

21,868 113,910 57,703 183,507 0.00 0.50 1.00 1.50 2.00 2.50 3.00 30,000 60,000 90,000 120,000 150,000 180,000 BH - Yes BH- No Rate Unique Patients/ED Encounters

Unique Patients ED Encounters Rate

16.1% 83.9% Unique Patients BH - Yes BH- No 23.9% 76.1% ED Encounters BH - Yes BH- No

  • 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

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Demographic Summary

  • 0-17 age group had the largest number of unique patients and

encounters, while 18-30 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

March 2012-February 2013

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Patient Location to Nearest Facility

  • 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

  • 3For 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

  • 4For adult patients, Dell

Children's Hospital was excluded from distance calculations

March 2012-February 2013

Unique Patients Percent Unique Patients Percent TOTAL 31,968 100.0 68,737 100.0 Nearest Facility Clinic 26,018 81.4 54,165 78.8 Hospital 5,950 18.6 14,572 21.2 Distance to Clinic3 <1 mi 11,749 36.8 23,549 34.3 1-1.99 mi 9,448 29.6 20,505 29.8 2-4.99 mi 8,178 25.6 17,779 25.9 5-9.99 mi 1,790 5.6 5,163 7.5 10+ mi 803 2.5 1,741 2.5 Distance to Hospital4 <1 mi 2,581 8.1 5,521 8.0 1-1.99 mi 5,188 16.2 12,103 17.6 2-4.99 mi 18,849 59.0 40,162 58.4 5-9.99 mi 3,761 11.8 8,187 11.9 10+ mi 1,589 5.0 2,764 4.0 Clinic User Clinic Non-User

  • Distance to facility does not seem to be a factor
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Patient Location to Nearest Facility

  • 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.

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 3.45 5.96 39.0% 93.4% Adults 3.48 5.79 36.4% 89.4% Day/Time Weekday During Clinic Hours 3.5 5.92 36.7% 90.9% Weekday During Non-Clinic Hours 3.45 5.75 37.9% 90.6% Weekend 3.45 5.88 37.3% 90.9%

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Zip Codes with 50+ Patients >5 Miles from Clinic

March 2012-February 2013

  • 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

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Patients with Clinic Visits

March 2012-February 2013

  • Patients with clinic

visits tend to live in or near Central Austin

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Patients with No Clinic Visits

March 2012-February 2013

  • Patients with no clinic

visits tend to live in SE and Central Austin

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BH Patients

March 2012-February 2013

  • BH patients tend to

live in or near Central Austin as well as East

  • f I35
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NYU Algorithm

March 2012-February 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

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

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NYU Algorithm Category Distribution

March 2012-February 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 780.6 FEVER UNSPECIFIED 43.1% 37.3% 0.0% 19.6% 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% 789.09 ABDOM PAIN OT/MULTI SITE 0.0% 67.0% 0.0% 33.0% 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% 787.03 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% 782.1 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% 465.9 ACUTE URI UNSPEC 0.0% 82.3% 17.7% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 959.01 HEAD INJURY UNSPEC 0.0% 0.0% 0.0% 0.0% 100.0% 0.0% 0.0% 0.0% 0.0%

ICD-9 Code Diagnosis Non- Emergent Emergent, Primary Care Treatable Emergent, ED Care Needed, Preventable/ Avoidable Emergent, ED Care Needed, Not Preventable/ Avoidable 780.6 FEVER UNSPECIFIED 43.1% 37.3% 0.0% 19.6% 786.2 COUGH 64.7% 23.5% 0.0% 11.8% 789.09 ABDOM PAIN OT/MULTI SITE 0.0% 67.0% 0.0% 33.0% 729.5 PAIN IN LIMB 70.8% 16.7% 0.0% 12.5%

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Potentially Preventable ED Visits by Group

Potentially Preventable 58.8% Emergent, ED Care Needed, Not Preventable/ Avoidable 11.4% Injury 16.7% Mental Health Related 1.6% Alcohol Related 1.2% Drug Related (excluding alcohol) 0.2% Not in a Special Category, and Not Classified 10.1%

Non- Emergent 52.5% Emergent, Primary Care Treatable 41.3% Emergent, ED Care Needed, Preventable/ Avoidable 6.2%

  • 58.8% or 141,822 of all ED Visits

were Potentially Preventable

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

Potentially Preventable

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Potentially Preventable ED Visits by Group

Potentially Preventable 61.5% Emergent, ED Care Needed, Not Preventable / Avoidable 11.1% Injury 17.4% Mental Health Related 0.0% Alcohol Related 0.0% Drug Related (excluding alcohol) 0.0% Not in a Special Category, and Not Classified 9.9%

  • 61.5% of non-BH ED Visits were Potentially Preventable, while 50.4% of BH ED

Visits were Potentially Preventable

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

Non BH Patients Potentially Preventable 50.4% Emergent, ED Care Needed, Not Preventable / Avoidable 12.0% Injury 14.5% Mental Health Related 6.7% Alcohol Related 4.8% Drug Related (excluding alcohol) 0.7% Not in a Special Category, and Not Classified 10.8% BH Patients

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% Potentially Preventable ED Visits by Type

March 2012-February 2013

58.8% Overall

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% Potentially Preventable Rate of ED Visits by Type

March 2012-February 2013

1.62 3.68 1.74 1.61 1.73 1.65 1.73 1.68 1.62 1.64 1.80 1.67 1.63

  • 0.50

1.00 1.50 2.00 2.50 3.00 3.50 4.00 No Yes No Yes No Yes No 1 2 3+ 1 2 3+ BH Medical Home Clinic User Clinic Visit ED Visit

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% Potentially Preventable by ED Visits

29.1% 31.3% 32.3% 23.4% 24.8% 24.8% 3.1% 3.7% 4.1% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 1 visit 2 visits 3+ Visits Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

By Number of ED Visit

March 2012-February 2013

58.8% Overall

55.6% 59.8% 61.2%

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

percent in Non-Emergent

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% Potentially Preventable by ED Visits - Age

37.3% 31.5% 27.3% 30.3% 26.6% 29.7% 8.8% 8.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 1-2 ED Visists 3+ ED Visits 51-64 Years 31-50 Years 18-30 Years 0-17 Years

By Number of ED Visit

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% Potentially Preventable by ED Visits - Ethnicity

39.8% 31.5% 9.8% 9.9% 45.4% 56.2% 5.0% 2.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 1-2 ED Visists 3+ ED Visits Other Hispanic Black White

By Number of ED Visit

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% Potentially Preventable by ED Visits - Payor

11.0% 6.7% 7.1% 12.7% 39.1% 51.7% 36.0% 26.8% 6.9% 2.6% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 1-2 ED Visists 3+ ED Visits Other Self Pay and SFS Medicaid County Indigent Charity

By Number of ED Visit

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% Potentially Preventable by ED Visits

32.6% 25.6% 25.3% 21.2% 3.7% 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 BH Patient Status

March 2012-February 2013

58.8% Overall

61.5% 50.4%

  • The ED Visits among BH patients are less likely to be potentially preventable compared to

non-BH patients

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% ED Visits by Payor Mix

46.7% 47.4% 45.6% 28.1% 30.9% 23.0% 13.8% 15.1% 11.5% 8.5% 3.3% 17.8% 2.8% 3.3% 2.1% 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

March 2012-February 2013 SFS– Sliding Fee Scale *Payor Mix at ED Encounter

  • 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
  • nly 3.3% among Clinic Non-Users
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% Potentially Preventable ED Visits by Payor Mix

34% 38% 33% 25% 32% 25% 25% 26% 23% 19% 2% 2% 4% 5% 2% 0% 10% 20% 30% 40% 50% 60% 70% Charity County Indigent Medicaid Self Pay and SFS Other Emergent, ED Care Needed, Preventable/ Avoidable Emergent, Primary Care Treatable Non-Emergent

Combined Clinic User and Non User

March 2012-February 2013 *Payor Mix at ED encounter

  • 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

58.8% Overall

61.% 65.5% 62.4% 52% 53.1%

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% Potentially Preventable ED Visits by Payor Mix*

34.6% 38.2% 33.5% 23.6% 31.4% 24.4% 24.5% 25.5% 22.1% 18.5% 1.8% 2.2% 3.5% 5.1% 1.6% 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

Clinic Non User

March 2012-February 2013 *Payor Mix at ED encounter

58.8%

61.% 64.9% 62.5% 50.9% 51.5%

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% Potentially Preventable ED Visits by Payor Mix*

32.9% 37.9% 32.7% 26.8% 35.2% 26.2% 25.6% 25.5% 23.7% 21.7% 2.4% 2.1% 4.0% 4.3% 1.2% 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

Clinic User

March 2012-February 2013 *Payor Mix at ED encounter

58.8%

61.5% 65.7% 62.2% 54.8% 58.1%

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Potentially Preventable ED Visits by BH

27.2% 61.4% 53.9% 64.2% 27.6% 59.5% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 50,000 100,000 150,000 200,000 250,000 All Yes All No <18 Yes <18 No Adult Yes Adult No Total Encounter Preventable Encounters Percent

  • 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

All Yes No <18 Yes No Adult Yes No

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BH ED Encounters – Frequent Diagnoses

Diagnoses Encounters Percent Total ED Encounters w/ BH Diagnosis 17,764 100.0 Primary BH Diagnosis 6,960 39.2% Nondependent Drug Abuse 2,262 12.7% Neurotic Disorders 1,692 9.5% Depressive Disorder Not Elsewhere Classified 620 3.5% Alcohol Dependence Syndrome 443 2.5% Other Nonorganic Psychoses 401 2.3% Affective Psychoses 386 2.2% Schizophrenic Disorders 263 1.5% Special Symptom Not Elsewhere Classified 209 1.2% Alcohol-Induced Mental Disorders 190 1.1% Drug Psychoses 145 0.8%

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Potentially Preventable ED Visits by Chronic Diagnosis

35.3% 60.5% 20.9% 64.6% 32.7% 58.5% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 50,000 100,000 150,000 200,000 250,000 All Yes All No <18 Yes < 18 No Adult Yes Adult No Total Encounter Preventable Encounters Percent

  • Chronic Dx Primary at the ED visit
  • Less likely to have a potentially preventable ED visit if there is a Chronic DX

All Yes No <18 Yes No Adult Yes No

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Potentially Preventable ED Visits by Day of Week

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Encounter Preventable Encounters Percent

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Potentially Preventable ED Visits by Time of Day

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 12:00 am - 5:59 am 6:00 am - 11:59 am 12:00 pm - 5:59 pm 6:00 pm - 11:59 pm Total Encounter Preventable Encounters Percent

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Potentially Preventable ED Visits Day and Time

30.4% 36.3% 36.0% 29.3% 30.3% 28.9% 30.7% 26.5% 26.9% 9.6% 6.9% 8.2% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Clinic Hrs Non-Clinic Hrs Wk End 51-64 Years 31-50 Years 18-30 Years 0-17 Years

Age

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Potentially Preventable ED Visits Day and Time

36.2% 34.8% 36.6% 10.3% 9.5% 9.3% 49.9% 52.0% 50.3% 3.6% 3.7% 3.8% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Clinic Hrs Non-Clinic Hrs Wk End Other Hispanic Black White

Ethnicity

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Potentially Preventable ED Visits Day and Time

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

Payor

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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