Exploratory Analysis of Observation Stay (Text Version)

On September 14, 2009, Pamela Owens made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.48 MB) (Plugin Software Help).

Slide 1

Characteristics of Emergency Departments with High and Low Volumes of Mental Health / Substance Abuse Cases

Pamela Owens, Ph.D.
Carol Stocks, M.S.
September, 2009
AHRQ Annual Meeting

Slide 2

Background

• Majority of emergency departments (EDs) (32%) have < 10,000 visits per year. (NEDI-USA).
• Less than 1/5 of hospitals are responsible for 63% of care.
• Patients with mental health and/or substance abuse (MHSA) conditions represent a considerable and growing number of all ED visits (Hospital-Based Emergency Care, IOM report, 2007).

Slide 3

Background

• Patients with MHSA conditions seen in the ED tend to require resource-intensive care and have high admission rates.
• Little is known about the characteristics of the EDs in which these patients are treated.

Slide 4

Research Questions

• What is the burden of MHSA care on EDs?
• What are the characteristics of EDs with high and low volume of MHSA cases?

Slide 5

Study Objectives

• To describe the distribution of MHSA cases seen in community hospital EDs
• To describe the characteristics of community hospital EDs with high and low volume MHSA cases
  • Characteristics of the hospitals
  • Characteristics of the visits

Slide 6

Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS), 2006

• Nationally representative of all community hospital EDs (i.e., short-term, non-Federal, non-rehabilitation hospital-based EDs)
• 20% stratified sample of hospital-based EDs and includes all ED visits, regardless of admission status and payer
• Drawn from a sample of over 950 hospitals in 24 states
• Contains 26 million ED records, weighted to represent 120 million ED visits nationally

Additional information on the HCUP at www.hcup-us.ahrq.gov

Slide 7

MHSA-related visit : Principal/ primary and/or secondary MHSA CCS code:

• Adjustment disorders (650)
• Anxiety disorders (651)
• Disruptive behavior disorders (652)
• Delirium (653)
• Disorders diagnosed in childhood (655)
• Impulse disorders (656)
• Mood disorders (657)
• Personality disorders (658)
• Alcohol-related disorders (660)
• Substance-abuse disorders (661)
• Suicide and intentional self-inflicted injury (662)
• Screening and history of MHSA (663)
• Miscellaneous MHSA conditions (670)

More information on the Clinical Classification Software (CCS) at www.hcup-us.ahrq.gov/tools

Slide 8

Methods: Measures

• Volume of MHSA Conditions (# of visits)
  • < 1,000 MHSA-related cases per year
  • 1,000-4,999 MHSA-related cases per year
  • 5,000-9,999 MHSA-related cases per year
  • 10,000+ MHSA-related cases per year
• Volume of MHSA Conditions (% of caseload)
  • < 10%
  • 10% to 20%
  • > 20%

Slide 9

Methods: Measures

• Hospital characteristics
  • Region of the country
  • Teaching status
  • Location
  • Trauma status
• Visit characteristics
  • Patient demographics
  • Primary expected payer
  • Disposition of the patient upon discharge

Slide 10

Results

Number of Emergency Departments by Number of MHSA-related Visits (N=21,475,037)

Graph showing:

• Number of MHSA-related visits in 2006 is < 1,000 (28.9%)
  • 581,028 visits, 2.7%
  • Number of Emergency Departments (EDs) is 1,399
• Number of MHSA-related visits in 2006 is 1,000-4,999 (36.2%)
  • 4,354,505 visits, 20.3%
  • Number of Emergency Departments (EDs) is 1,753
• Number of MHSA-related visits in 2006 is 5,000-9,999 (22.1%)
  • 7,152,242 visits, 33.3%
  • Number of Emergency Departments (EDs) is 1,072
• Number of MHSA-related visits in 2006 is 10,000+ (12.8%)
  • 9,387,262 visits, 43.7%
  • Number of Emergency Departments (EDs) is 621

Slide 11

Results

Percent of EDs with Specified Caseload Volume by Type of ED

Graph showing:

• Type of EDs is < 1000 (Defined by the Number of ED MHSA-related Visits)
  • Percent of EDs 75.9% (< 10% of caseload MHSA-related)
  • Percent of EDs 21.7% (10%-20% of caseload MHSA-related)
  • Percent of EDs 2.5% (> 20% of caseload MHSA-related)
• Type of EDs is 1,000-4,999 (Defined by the Number of ED MHSA-related Visits)
  • Percent of EDs 28.0% (< 10% of caseload MHSA-related)
  • Percent of EDs 56.6% (10%-20% of caseload MHSA-related)
  • Percent of EDs 15.3% (> 20% of caseload MHSA-related)
• Type of EDs is 5,000-9,999 (Defined by the Number of ED MHSA-related Visits)
  • Percent of EDs 3.3% (< 10% of caseload MHSA-related)
  • Percent of EDs 52.5% (10%-20% of caseload MHSA-related)
  • Percent of EDs 44.1% (> 20% of caseload MHSA-related)
• Type of EDs is 10,000+ (Defined by the Number of ED MHSA-related Visits)
  • Percent of EDs 0% (< 10% of caseload MHSA-related)
  • Percent of EDs 20% (10%-20% of caseload MHSA-related)
  • Percent of EDs 80% (> 20% of caseload MHSA-related)

Slide 12

Results

Characteristics of EDs by Volume of MHSA (Percent of Hospitals)

Slide 13

Results

Characteristics of Visits for EDs with Low and High Volume of MHSA-related Cases

Slide 14

Results

Top All-Listed MHSA Conditions by EDs with Low and High Volume of MHSA-related Cases

Slide 15

Results

Percent Admitted, Transferred to Long Term Care (LTC), or Transferred to Short Term Care (STC) by MHSA Volume of ED

Graph showing:

• MHSA Volume of ED is < 10% (% of Caseload)
  • Percent of EDs 10.5% (Admitted)
  • Percent of EDs 2.9% (Transferred to LTC)
  • Percent of EDs 2.3% (Transferred to STC)
• MHSA Volume of ED is 10%-20% (% of Caseload)
  • Percent of EDs 15.8% (Admitted)
  • Percent of EDs 4.3% (Transferred to LTC)
  • Percent of EDs 1.5% (Transferred to STC)
• MHSA Volume of ED is > 20% (% of Caseload)
  • Percent of EDs 17.2% (Admitted)
  • Percent of EDs 4.9% (Transferred to LTC)
  • Percent of EDs 1.1% (Transferred to STC)

Slide 16

Summary

• MHSA care accounts for a substantial portion of ED care (17.9%).
• Majority of MHSA cases seen in a few high volume hospitals
• Low MHSA volume hospitals are typically
  • Midwest and South
  • Rural areas
  • Non-trauma
• High MHSA volume hospitals are more likely
  • In the South
  • Non-teaching in urban areas
  • Trauma hospitals

Slide 17

Summary

• Visits in low MHSA volume hospitals typically
  • Patients are younger and from rural areas
  • More likely to have Medicaid as expected payer
  • More likely to be for patients with anxiety, alcohol and substance abuse and delirium
  • Less likely to result in admission or transfer to long-term care; more likely to be transferred to short-term care
• Visits in high MHSA volume hospitals typically
  • Patients are from urban areas
  • More likely to have uninsured visits
  • More likely to screen for MHA conditions
  • More likely to result in admission or transfer to long-term care; less likely to result in transfer to short-term care

Slide 18

Limitations

• Did not present MHSA-related cases versus all other cases
• Analysis solely descriptive (did not control for severity or case-mix)
• Analysis at the level of the visit not the patient (not look at revisits)
• Claims data compiled for reimbursement purposes (under-reporting possible)

Slide 19

Conclusions

• MHSA care accounts for a substantial portion of ED care.
• Considerable variation in the characteristics of EDs treating MHSA patients.
• Additional research needed.
• Need to address the quality and value of MHSA care received in high versus low MHSA volume EDs in the context of resources.