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).

---

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)

Characteristic	Volume of MHSA (% of caseload)
	Overall	< 10%	10% to 20%	> 20%
Number of Hospitals	4,845	1,588	1,983	1,273
Region
Northeast	13.2	8.0	19.5	9.9
Midwest	29.3	36.1	24.8	27.7
South	39.0	41.0	30.4	49.8
West	18.5	14.9	25.2	12.6
Teaching and Location
Urban, teaching	18.3	6.8	20.5	29.1
Urban, non-teaching	39.9	24.0	46.5	49.6
Non-Urban	41.8	69.2	33.0	21.3
Location: MSA	58.2	30.9	67.0	78.7
Trauma Hospital	14.4	3.7	17.1	23.5

Slide 13

Results

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

	Volume of MHSA (% of caseload)
	Overall	< 10%	10% to 20%	> 20%
Number of Visits	120,033,750	21,161,843	56,415,345	42,456,562
Female	54.4	54.1	54.4	54.5
Mean Age	38.3	34.2	38.9	39.5
Residence
Large metropolitan	48.3	34.8	54.1	47.4
Small metropolitan	31.9	23.4	29.7	39.0
Micropolitan	12.1	21.4	10.1	10.2
Noncore	7.7	20.4	6.2	3.4
Expected payer
Medicare	20.3	17.8	20.6	21.1
Medicaid	21.7	24.8	20.5	21.7
Private	34.8	36.0	36.8	31.5
Uninsured	17.8	16.6	17.1	19.3

Slide 14

Results

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

	Volume of MHSA (% of caseload)
	Overall	< 10%	10% to 20%	> 20%
Number of Visits	21,475,036	1,558,443	8,207,192	11,709,401
Secondary MHSA dx only	79.8	71.1	75.0	84.3
Screening for MHSA Disorders	48.1	20.9	34.7	61.1
Mood Disorders	23.5	23.1	26.0	21.7
Anxiety Disorders	14.5	23.0	16.9	11.7
Alcohol-related Disorders	13.0	15.3	15.9	10.7
Substance Use Disorders	10.2	10.9	11.5	9.1
Delirium	9.8	14.3	12.1	7.5
Schizophrenia	5.7	6.6	6.3	5.1
Intentional self-inflicted injury	3.5	4.4	3.8	3.1

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.