Examining Potentially Avoidable Emergency Department Encounters and Hospital Admissions (Text Version)

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

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Slide 1

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

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

• 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

• >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

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

• 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)

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

Selected Prevention Quality Indicators	Total Events	Percentage of Total Events	Average 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	$3,816,656,449	92.6%
ED events	505,297	(46.3)	$601	$303,709,322	7.4%
Combined IP and ED events	1,092,616	(100.0)	$3,771	$4,120,365,770	100.0%

Slide 9

Study Results: Across 4 States

Selected Prevention Quality Indicators	Total Events	Percentage of Total Events	Average 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%

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Study Results: Across 4 States

Selected Prevention Quality Indicators	Total Events	Percentage of Total Events	Average Costs per Visit	Aggregate Costs (over 24-month period)	Percentage of Combined Costs
Diabetes (Pediatric)
IP events	4,045	(80.4)	$4,013	$16,230,717	93.2%
ED events	989	(19.7)	$1,207	$1,193,825	6.9%
Combined IP and ED events	5,034	(100.0)	$3,461	$17,424,542	100.0%
Diabetes (Adult)
IP events	37,530	(79.9)	$5,326	$199,871,282	95.4%
ED events	9,463	(20.1)	$1,015	$9,602,456	4.6%
Combined IP and ED events	46,993	(100.0)	$4,458	$209,473,739	100.0%

Slide 11

 

Study Results: Across 4 States

Selected Prevention Quality Indicators	Total Events	Percentage of Total Events	Average 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%

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Study Results: Across 4 States

Selected Prevention Quality Indicators	Total Events	Percentage of Total Events	Average Costs per Visit	Aggregate Costs (over 24-month period)	Percentage of Combined Costs
Gastroenteritis (Pediatric)
IP events	20,635	(12.8)	$1,929	$39,810,401	40.7%
ED events	140,392	(87.2)	$414	$58,104,537	59.3%
Combined IP and ED events	161,027	(100.0)	$608	$97,914,939	100.0%

Slide 13

 

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 Condition	Number of Events (in thousands)
	IP Only Events	IP and ED Events	ED Only Events
Pediatric Asthma	5	10	95
Adult Asthma	6	30	140
Elderly Asthma	4	15	12
Pediatric Diabetes	1	3
Adult Diabetes	4	35	10
Adult CHF	40	195	29
Bacterial Pneumonia	35	175	90
Pediatric Gastroenteritis	8	13	135

Slide 14

 

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

• 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

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

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

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."

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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."

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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."

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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

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)

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.