Examining Potentially Avoidable Emergency Department Encounters and Hospital Admissions

Slide presentation from the AHRQ 2010 conference.

On September 28, 2010, Claudia Steiner made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (3.2 MB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

Examining Potentially Avoidable Emergency Department Encounters and Hospital Admissions

Examining Potentially Avoidable Emergency Department Encounters and Hospital Admissions

Claudia Steiner MD, MPH
Agency for Healthcare Research and Quality
AHRQ Annual Meeting • September 2010

Slide 2

Text Description is below the image

Assess the impact of including both IP and ED data when evaluating potentially preventable admissions and visits

Two images: a doctor/patients and an ambulance are shown.

Previous research primarily considers IP data

Friedman B., Basu J. The Rate and Cost of Hospital Readmissions for Preventable Conditions. Med Care Res Rev 2004; 61; 225.

Slide 3

Objectives. Text Description is below the image.

Objectives

  • Understand the impact of including both IP and ED data when evaluating:
    • The utilization of potentially preventable healthcare encounters.
    • The costs of potentially preventable healthcare encounters.

Slide 4

Study Design. Text Description is below the image.

Study Design

  • >Design: retrospective, observational cohort study
  • Timeframe: 23-months (January 2005—November 2006)
  • Four States: AZ, FL, NE, and TN:
    • Geographic and demographic variability
    • Represent 8.6 million discharges

Slide 5

Three Primary AHRQ Resources. Text Description is below the image.

Three Primary AHRQ Resources

Image: The cover of the Guide to Prevention Quality Indictors.

Prevention Quality Indictors (Asthma {pediatric, adult, elderly}, Diabetes {pediatric, adult}, CHF, Bacterial Pneumonia, and Pediatric Gastroenteritis) } Quality Measures.

Image: A green data bin labeled SID [State Inpatient Databases].

HCUP State Inpatient Databases (AZ, FL, NE, TN) } Hospital discharge databases.

Image: A red data bin labeled SEDD [State Emergency Department Databases].

HCUP State ED Databases (AZ, FL, NE, TN) } Hospital discharge databases.

Slide 6

"Study Design. Text Description is below the image.

Study Design

  • HCUP SID:
    • Encounter / discharge level
    • All discharges from all community hospitals in participating States
  • HCUP SEDD:
    • Encounter / visit level
    • All treat and release encounters from all community hospital emergency departments in participating States
  • AHRQ PQIs:
    • Applied the standard definitions (numerators and denominators) provided by the software package available through AHRQ
    • Each condition defined using the principle diagnosis field
    • Readmissions limited to the same condition

Slide 7

Impact of using all-listed vs. first-listed diagnosis (HCUP SEDD). Text Description is below the image.

Impact of using all-listed vs. first-listed diagnosis (HCUP SEDD)

 AHRQ Prevention Quality Indicator (PQI)

 No. ED Visits using first-listed DX

No. ED Visits using all-listed DX 

Pct increase using all-listed DX 

Angina (Adult)—PQ13

4,211

   7,647

82%

Asthma (Adult)—PQ15

27,573

  103,507

275%

Asthma (Elderly)—PQ15B

2,893

13,648

372%

Asthma (Pediatric)—PD14

23,358

55,535

138%

CHF (Adult)—PQ08

7,373

34,775

372%

Diabetes (Adult)—PQ01

564

732

30%

Diabetes (Pediatric)—PD15

353

386

9%

Gastroenteritis (Ped)—PD16

32,715

36,879

13%

Pneumonia (Adult)—PQ11

27,113

33,309

23%

Total across PQIs

  126,153

     286,418

127%

Source: Agency for Healthcare Quality and Research, Healthcare Cost and Utilization Project, State Emergency Department Databases, Arizona and Nebraska, 2006-2007.

Slide 8

Study Results: Across 4 States. Text Description is below the image.

Study Results: Across 4 States

Selected Prevention Quality IndicatorsTotal EventsPercentage of Total EventsAverage Costs
per Visit
Aggregate Costs
(over 24-month period)
Percentage of
Combined Costs

All 8 PQI Conditions

 IP events

 587,319(53.8) $6,498 $3,816,656,44992.6%

 ED events

 505,297(46.3) $601 $303,709,3227.4%

 Combined IP and ED events

 1,092,616(100.0) $3,771 $4,120,365,770100.0%

Slide 9

Study Results: Across 4 States. Text Description is below the image.

Study Results: Across 4 States

Selected Prevention Quality IndicatorsTotal EventsPercentage of Total EventsAverage Costs
per Visit
Aggregate Costs
(over 24-month period)
Percentage of
Combined Costs

Asthma (Pediatric)

IP events

  16,674

(15.6)

 $2,986

 $49,791,099

58.7%

ED events

  90,015

(84.4)

 $389

 $35,060,164

41.3%

Combined IP and ED events

 106,689

(100.0)

 $795

 $84,851,263

100.0%

Asthma (Adult)

IP events

  39,354

(23.0)

 $4,739

 $186,499,547

72.7%

ED events

 131,707

(77.0)

 $533

 $70,158,082

27.3%

 Combined IP and ED events

 171,061

(100.0)

 $1,500

 $256,657,628

100.0%

Asthma (Elderly)

 IP events

  21,507

(62.2)

 $6,076

 $130,666,333

92.7%

ED events

  13,075

(37.8)

 $784

 $10,244,981

7.3%

Combined IP and ED events

  34,582

(100.0)

 $4,075

 $140,911,313

100.0%

Slide 10

 Study Results: Across 4 States. Text Description is below the image.

Study Results: Across 4 States

Selected Prevention Quality IndicatorsTotal EventsPercentage of Total EventsAverage Costs
per Visit
Aggregate Costs
(over 24-month period)
Percentage of
Combined Costs

Diabetes (Pediatric)

IP events

   4,045(80.4) $4,013 $16,230,71793.2%

ED events

989(19.7) $1,207 $1,193,8256.9%

Combined IP and ED events

   5,034(100.0) $3,461 $17,424,542100.0%

Diabetes (Adult)

IP events

  37,530(79.9) $5,326 $199,871,28295.4%

ED events

   9,463(20.1) $1,015 $9,602,4564.6%

Combined IP and ED events

  46,993(100.0) $4,458 $209,473,739100.0%

Slide 11

Study Results: Across 4 States. Text Description is below the image.  

Study Results: Across 4 States

Selected Prevention Quality IndicatorsTotal EventsPercentage of Total EventsAverage Costs
per Visit
Aggregate Costs
(over 24-month period)
Percentage of
Combined Costs

Congestive Heart Failure (Adult)

IP events

 239,060

(88.8)

 $7,099

 $1,697,021,632

97.8%

ED events

  30,185

(11.2)

 $1,244

 $37,545,031

2.2%

Combined IP and ED events

 269,245

(100.0)

 $6,442

 $1,734,566,663

100.0%

Bacterial Pneumonia (Adult)

IP events

 208,514

(70.0)

 $7,178

 $1,496,765,438

94.8%

ED events

  89,471

(30.0)

 $914

 $81,800,246

5.2%

Combined IP and ED events

 297,985

(100.0)

 $5,297

 $1,578,565,683

100.0%

Slide 12

 Study Results: Across 4 States. Text Description is below the image.

Study Results: Across 4 States

Selected Prevention Quality IndicatorsTotal EventsPercentage of Total EventsAverage Costs
per Visit
Aggregate Costs
(over 24-month period)
Percentage of
Combined Costs

Gastroenteritis (Pediatric)

IP events

  20,635(12.8) $1,929 $39,810,40140.7%

ED events

 140,392(87.2) $414 $58,104,53759.3%

Combined IP and ED events

 161,027(100.0) $608 $97,914,939100.0%

Slide 13

 Distribution of IP and ED Events by PQI Condition. Text Description is below the image.

Distribution of IP and ED Events by PQI Condition

Image: A bar chart shows the Distribution of IP and ED Events by PQI Condition:

PQI ConditionNumber of Events (in thousands)
IP Only EventsIP and ED EventsED Only Events
Pediatric Asthma51095
Adult Asthma630140
Elderly Asthma41512
Pediatric Diabetes13 
Adult Diabetes43510
Adult CHF4019529
Bacterial Pneumonia3517590
Pediatric Gastroenteritis813135

Slide 14

 Which PQIs were most impacted by adding ED data? Text Description is below the image.

Which PQIs were most impacted by adding ED data?

Percent of visits that were treat-and-release ED visits versus IP admissions:

  • Pediatric Gastroenteritis (83%)
  • Asthma, Pediatric (82%)
  • Asthma, Adult (81%)
  • Asthma, Elderly (41%)
  • Bacterial Pneumonia (28%)
  • Diabetes, Adult (24%)
  • Diabetes, Pediatric (20%)
  • Congestive heart failure (11%)

Greatest ED impact on utilization:
Pediatric gastroenteritis and Non-elderly asthma.

Lowest ED impact on utilization:
CHF

Slide 15

Conclusions. Text Description is below the image.  

Conclusions

  • Substantial impact of ED visits on overall hospital utilization for eight potentially preventable admissions.
    • Accounting for ED visits more than doubled the number of visits (by 500K).
  • Variable impact of ED visits on overall hospital costs for eight potentially preventable admissions.
    • Increased overall costs by 7% (by $243M).

Slide 16

Project Team. Text Description is below the image.  

Project Team

AHRQ [Image: AHRQ logo]:

  • Claudia Steiner, MD, MPH
  • Barry Friedman, PhD
  • Joanna Jiang, PhD

Thomson Reuters [Image: Thomson Reuters logo]:

  • Dan Whalen
  • Marguerite Barrett, MS
  • Minya Sheng
  • Chaya Merrill, PhD

Slide 17

 Considerations. Text Description is below the image.

Considerations

Editor, Annals of Emergency Medicine (based upon almost identical comments from Reviewer1 and Reviewer2):

"The eight selected conditions are very relevant to emergency physicians... However, the reviewers had several concerns that limit our ability to publish your manuscript.

First, ED care and hospitalization are non-mutually exclusive steps in a pathway in the United States—the decisions about whether to visit the ED are up to patients while the decisions about whether to get hospitalized are up to emergency physicians and physicians in the community.

In addition, PQIs were developed exclusively for use in the inpatient setting, and are not necessarily valid for ED visits."

Slide 18

 Considerations. Text Description is below the image

Considerations

Reviewer 1, Annals of Emergency Medicine:

Misclassification Bias:

"One means of assessing the degree of misclassification would be to calculate the proportion of the inpatient (IP) diagnoses that match the ED "reason for visit" for the IP hospitalizations that were admitted through the ED."

Slide 19

Considerations. Text Description is below the image  

Considerations

Reviewer 1, Annals of Emergency Medicine:

"Should preventable hospital care be viewed the same as "preventable" ED care? Perhaps these entities are different and should be analyzed as distinct entities."

Slide 20

Considerations. Text Description is below the image  

Considerations

Reviewer 2, Annals of Emergency Medicine:

"ED care is ambulatory care and not inpatient care. This paper assumes that ED patients that have diagnoses that when admitted fall within PQI measures are the same as admitted patients with these diagnoses. But EDs treat and release patients who were likely less sick, did have their hospitalization prevented by definition, and the importance of including such treat and release patients in the PQI measure is unclear."

Slide 21

Considerations. Text Description is below the image  

Considerations

Reviewer 2, Annals of Emergency Medicine:

"The PQI was developed for inpatient hospitalization measurement, whereas alternative methods such as the Billings algorithm have been developed to assess preventable ED care."

Slide 22

 Considerations. Text Description is below the image

Considerations

Reviewer 2, Annals of Emergency Medicine:

"The authors even note that many ED codes are symptom-based codes, so the application of PQI to ED codes raises many concerns:

a. PQI is designed for inpatient discharge codes not ambulatory codes.

b. PQI has never been validated for application to ED patients; there is no reason to believe that ED patients with treat and release conditions and/or these codes for CHF, asthma or diabetes are similar. This needs to be studied."

Slide 23

 Healthcare Cost and Utilization Project (HCUP). Text Description is below the image.

Healthcare Cost and Utilization Project (HCUP)

The largest collection of multi-level, all-payer, encounter-level, health care data.

Image: The HCUP logo is shown superimposed over photographs of medical professionals doing a variety of jobs.

Current as of December 2010
Internet Citation: Examining Potentially Avoidable Emergency Department Encounters and Hospital Admissions. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/steiner2/index.html