2012 Update on U.S. Emergency Care and Longitudinal Trends (1995-2010)

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Slide 1

2012 Update on U.S. emergency care and longitudinal trends (1995-2010)

Jesse M. Pines, MD, MBA, MSCE and Mark Zocchi, MPH

AHRQ National Meeting
September 10, 2012

Images: The logos of AHRQ and the George Washington University are shown.

Slide 2

Disclosures

• Funding and support:
  • Centers for Medicare and Medicaid Services.
  • National Quality Forum.
  • Agency for Healthcare Research and Quality.
  • Robert Wood Johnson Foundation.
  • Saudi Arabian Cultural Mission.
  • University of Cincinnati.

Slide 3

Project co-authors / collaborators

• Ryan Mutter, PhD, AHRQ.
• Lan Zhao, PhD, Social and Scientific Systems.

Slide 4

Objectives

• Provide a update on emergency care for 2012.
  • Where are we since the Institute of Medicine (IOM) report?
• Describe emergency care policy issues and longitudinal trends in emergency care in the U.S.

Slide 5

Introduction

• Why does emergency care matter?

Image: A figure depicts the input-throughput-out conceptual model of emergency department (ED) crowding:

Input

Emergency Care:

• Seriously ill and injured patients from the community.
• Referral of patients with emergency conditions.

Unscheduled urgent care:

• Lack of capacity for unscheduled care in the ambulatory care system.
• Desire for immediate care (e.g., convenience, conflicts with job, family duties).

Safety net care:

• Vulnerable populations (e.g., Medicaid beneficiaries, the uninsured).
• Access barrier (e.g., financial, transportation, insurance, lack of usual source of care).

→

Demand for ED care →

Ambulance diversion →

Throughput

• Patient arrives at ED →
• Triage and room placement →
• Diagnostic evaluation and ED treatment →
  • o Leaves without treatment complete.
  • o Patient disposition →

Output

• Admit to hospital ←→
• Transfer to other facility (e.g., skilled nursing, referral hospital) →
• Ambulatory care system →

Lack of access to follow-up care → Patient arrives at ED (under Throughput).

Lack of available staffed inpatient beds → ED boarding of inpatients (under Throughput).

Asplin, Ann Emerg Med 2003.

Slide 6

Institute of Medicine

• Future of Emergency Care Series (2006):
  • Hospital-Based Emergency Care: At the Breaking Point.
    • ED crowding, ambulance diversion, ED boarding very common.
      • Call to end boarding, except under "extreme" circumstances.
    • Emergency departments not prepared for mass-casualty events.
    • Call for greater health information technology, information-sharing.
• Emergency Medical Services: At the Crossroads.
• Emergency Care for Children: Growing Pains.

Images: The covers of the reports, Hospital-Based Emergency Care, Emergency Medical Services: At the Crossroads, and Emergency Care for Children: Growing Pains, are shown.

Slide 7

Where are we in 2012?

• ED crowding, diversion, ED boarding very common.

Image: A graph shows the mean hourly intervals versus average numbers of visits to the ED/occupation count for the years 2001 to 2008.

Pitts Pines, Ann Emerg Med 2012.

Slide 8

Where are we in 2012?

• ED crowding, diversion, ED boarding very common.

Image: A line graph shows trends in United States population and ED crowding by increase percentages from 2001 to 2008. The U.S. population shows a 7% increase during this period; the number of ED visits shows a 10% increase and the number of occupancies a 23% increase.

Pitts Pines, Ann Emerg Med 2012.

Slide 9

What is causing crowding?

• Visits are going up.
• The total time spent in the ED is rising faster.

Slide 10

What is causing crowding?

Pitts Pines, Ann Emerg Med 2012.

Slide 11

What is causing crowding?

Pitts Pines, Ann Emerg Med 2012.

Slide 12

Expanded literature on ED crowding

• ED crowding is associated with:
  • Poorer quality pain care.
  • Delays in medications.
  • Delays in critical tests.
  • Higher medication errors.
  • Higher rates of complications.
  • Lower quality care in pediatric asthma.
• ED boarding is associated with:
  • Higher medical errors.
  • Higher mortality rates.

Slide 13

Where are we in 2012?

• What has happened from a policy perspective?
  • 2008 ED National Quality Forum ED crowding measures:
    • ED LOS discharged, admitted, overall.
    • Left without being seen rate.
  • 2009 Diversion ban in Massachusetts.
  • 2011—ED LOS measures released on Hospital Compare.

Slide 14

Where are we in 2012?

• What may happen in the future?
  • 2012—ASPR-funded ED crowding/preparedness measurement concepts.
  • 2012 & beyond—ED LOS measures part of Value-Based Purchasing?

Slide 15

Where are we in 2012?

• 2012—Joint Commission Flow Standard (82% of hospitals).
• EP1: Hospital has a process that supports the flow of patients throughout the hospital.
• EP2: Hospital must plan and care for the patients who are admitted and whose bed is not ready or a bed is unavailable.
• EP3: Hospital must plan for the care for patients who are placed in an overflow location. (Appropriate care regardless of location)
• EP4: Hospital should have a policy and procedure on diversion.

Slide 16

Where are we in 2012?

• EP5: Hospitals must measure and set goals for the components of the patient flow process.
• EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.
• EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.
• EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.
• EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

Slide 17

Where are we in 2012?

• EP5: Hospitals must measure and set goals for the components of the patient flow process.
• EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.
• EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.
• EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.
• EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

Slide 18

Next policy questions

• Why do people come to the ED?
  • Beyond the critically ill.
  • What are alternatives?
  • How will new policy changes impact these trends?
• What care are people receiving?
  • Higher intensity care.
    • Advanced radiography, laboratory tests, IVs.
  • Sicker patients.
  • Admissions.
• How is the ED changing over time, compared to other parts of the system.
  • At what cost?

Slide 19

Why do so many people come to the ED?

Image: A table analyzes factors in reasons for people coming to the emergency department. Factors include medical necessity, convenience, ED preference, insurance limitations, and affordability.

Ragin, Acad Emerg Med 2005.

Slide 20

How does the ED compare to alternatives?

Image: A table compares characteristics and resources of care settings—emergency department versus office practice, urgent care clinics, and retail clinics. Characteristics compared include hours of operation, location, access, type of care, and type of provider.

Morgan Pines, Am J Manag Care 2012.

Slide 21

Policy changes and the ED

• Payment bundling, accountable care organizations:
  • Will this impact the ED?
    • How? Depends...
• Medical home model:
  • Early results that becoming a medical home is associated with lower ED visits.
• Diversion of low-acuity patients to alternative settings.
  • Wellpoint; others:
    • Has been somewhat effective, but may not reduce overall costs.

Slide 22

Why do people come to the ED?

Image: A table lists the ten leading reasons for emergency department visits for the United States in 2009:

• Stomach pain, cramps, and spasms.
• Fever.
• Chest pain and related symptoms.
• Cough.
• Headaches, pain in head.
• Shortness of breath.
• Back symptoms.
• Pain, site not referrable to a specific body system.
• Vomiting.
• Symptoms referrable to throat.

2009 NHAMCS data, CDC.

Slide 23

Why do people come to the ED

• The reasons people come to the ED (and get admitted to the hospital are not changing).
• There are just more and more people, and the growth is outpacing population expansion.

Image: A photograph shows a man clutching his abdomen and bending over slightly as if in pain.

Slide 24

How is the intensity of care changing?

• More intense care, higher complexity care.

SEDD 2004-2010: GA, HI, MA, MD, MO, NE, VT, WI
Emergency Department Visits: Percentage of Services (denominator = all ED records)

Image: A line graph shows the percentage of E/M Codes billed for emergency department visits from 2001 to 2010 and their increase or decrease during that period:

• 99281 - 2% decrease.
• 99282 - 6% decrease.
• 99283 - 11% decrease.
• 99284 - 3% decrease.
• 99285 - 21% increase.

Source: OIG analysis of PBAR National Procedure Summary files from 2001 to 2010.

Slide 25

How about hospital admissions?

Image: A line graph compares ED admission rates and Non-ED admission rates for APR-DRG Severity from 2002 to 2010. ED admission rates rise from 2.0 to ~2.3. Non-ED admission rates rise from just above 1.5 to ~ 1.8.

Healthcare Cost and Utilization Project (HCUP) data, AHRQ.

Slide 26

How about admission rates?

• Is the likelihood of admission increasing?

Slide 27

ED admission rates over time

Image: A line graph shows ED admission rates from 2002 to 2009. Admission rates are around 14% for 2002-2004, but rise to around 16% from 2005 to 2009.

HCUP data, AHRQ.

Slide 28

How about specific populations?

• ED admission rates are increasing for older adults.
  • CDC data.
  • 36.2% in 2001; 38.7% in 2009.
• Numbers of ICU admissions are increasing dramatically.
  • CDC data.
  • 2.76 million in 2002-2003.
  • 4.14 million in 2008-2009.

Pines, J Am Geriatric Soc 2012 (in press); Mullins Pines, Crit Care Med (under review).

Slide 29

Policy questions

• ED visits increasing.
• Patients are sicker, more ICU-bounds.
• Staying for more prolonged work-ups.
• Admission rates are unchanged on average.
  • Perhaps preventing some hospital admissions in younger patients?
• Next questions:
  • Where are ED visits increasing more?
  • What is happening to the supply of EDs?

Slide 30

Total U.S. ED volume v. # of EDs

Image: A line graph shows total ED volume in millions and number of EDs from 1995 to 2010. While the number of EDs decreases, ED volume rises from around 90 million to over 120 million.

HCUP data, AHRQ.

Slide 31

Profit v. non-profit v. public

Image: A line graph shows total ED volume in millions for profit, non-profit, and public hospitals from 1995 to 2010. ED volume for non-profit hospitals rises from 65 million to nearly 90 million.

HCUP data, AHRQ.

Slide 32

Urban v. rural location

Image: A line graph shows total ED volume in millions for urban and rural hospitals from 1995 to 2010. ED volume for urban hospitals rises from ~70 million to ~100 million.

HCUP data, AHRQ.

Slide 33

Hospital average ED volume v. # EDs

Image: A line graph shows hospital average ED volume in thousands and number of EDs from 1995 to 2010. While the number of EDs decreases slightly, ED volume rises from around 18,000 to 28,000.

HCUP data, AHRQ.

Slide 34

Growing role of ED admissions

Image: A line graph shows percentage of admissions to ED for congestive heart failure, pneumonia, acute myocardial infarction, and all admissions from 1993 to 2006. All types of admissions rise slightly, except for acute myocardial infarction, which decreases slightly.

Schuur Venkatesh, New Engl J Med 2012.

Slide 35

Average cost per admission

Image: A line graph shows average cost for ED and non-ED admissions from 1995 to 2010. ED admission costs rise from $6,000 to ~$10,000. Non-ED admission costs rise from ~$7,000 to ~$10,000.

HCUP data, AHRQ.

Slide 36

ED admissions as a cost driver

Image: A line graph shows total cost (in billions) for ED and non-ED admissions from 1995 to 2010. ED admission costs rise from ~$75 billion to nearly $200 billion. Non-ED admission costs rise from ~$110 billion to nearly $200 billion.

HCUP data, AHRQ.

Slide 37

Recap

• ED crowding and boarding:
  • How far have we come since the 2006 IOM Report.
• Trends in demand for emergency care in the U.S.
  • Will this go unabated?
  • What does this mean for U.S. healthcare costs?

Slide 38

Questions?