Article, Emergency Medicine

Characteristics of Medicaid enrollees with frequent ED use

a b s t r a c t

Background: Medicaid enrollees are disproportionately represented among patients with frequent Emergency Department (ED) visits, yet prior studies investigating Frequent ED users have focused on patients with all Insurance types.

Methods: This was a single center, retrospective study of Medicaid-insured frequent ED users (defined as >=4 ED visits/year not resulting in hospital admission) to assess patients’ sociodemographic and clinical characteristics and evaluate differences in these characteristics by frequency of use (4-6, 7-17, and >=18 ED visits).

Results: Twelve percent (n = 1619) of Medicaid enrollees who visited the ED during the 1-year study period were frequent ED users, accounting for 38% of all ED visits (n = 10,337). Most frequent ED users (n = 1165, 72%) had 4-6 visits; 416 (26%) had 7-17 visits, and 38 (2%) had >=18 visits. Overall, 67% had a primary care provider and 56% had at least one chronic medical condition. The most common ED diagnosis among patients with 4-6 visits was abdominal pain (7%); among patients with 7-17 and >=18 ED visits, the most common diagnosis was Alcohol-related disorders (11% and 36%, respectively). Compared with those who had 4-6 visits, patients with >=18 visits were more likely to be homeless (7% vs 42%, P b .05) and suffer from alcohol abuse (15% vs 42%, P b .05).

Conclusion: One out of 8 Medicaid enrollees who visited the ED had >=4 visits in a year. Efforts to reduce frequent ED use should focus on reducing barriers to accessing primary care. More tailored interventions are needed to meet the complex needs of adults with >=18 visits per year.

(C) 2013

Introduction

Frequent Emergency Department (ED) users, typically defined as patients with 4 or more ED visits in 1 calendar year, comprise only 8% of individuals who utilize the ED, yet are responsible for 20% of all ED visits [1]. Frequent ED users are patients with complex social needs, many of whom have Mental illness and other chronic diseases [2,3]. Compared with other ED users, frequent ED users are more likely to be hospitalized and to report overall higher use of outpatient health care services [4,5]. While all insurance groups have a subpopulation of enrollees who are frequent ED users, Medicaid enrollees compose the majority of frequent ED users [3,6,7].

policy makers and state government leaders, as well as Medicaid office directors, aware of this phenomena, are developing programs to help route Medicaid-enrolled frequent ED users to primary care

* Corresponding author.

E-mail address: [email protected] (R. Capp).

offices [8,9]. Yet there are no published data examining the unique characteristics of Medicaid-enrolled frequent ED users; instead, the current literature describes frequent ED users in general, combining the Medicaid population with the uninsured, privately insured, and Medicare populations [1,2,10,11]. Differences in insurance status and type are important to consider in the context of understanding and addressing frequent ED use. Medicaid enrollees typically face more barriers to timely primary care than those with private insurance, and may have different social and health needs than other patients. Such factors may impact the type and success of interventions to reduce ED utilization [12,13].

The objectives of this study were to characterize the socio- demographic and clinical characteristics and to investigate resource utilization associated with ED visits, among a population of Medicaid enrollees with frequent ED visits to an urban hospital within 1 year. We focused on patients who had at least 4 ED visits that did not result in hospital admissions with the assumption that this population utilizes ED services for potentially less acute reasons, and thus may be more appropriate for future interventions designed to reduce ED

0735-6757/$ – see front matter (C) 2013 http://dx.doi.org/10.1016/j.ajem.2013.05.050

frequent users“>psychiatric conditions and alcohol “>living situation, discharge disposi”>visits. Specifically, we describe the population’s characteristics upon entering the ED, such as chronic medical conditions, mental health and Substance use disorders, and how these vary by the number of ED visits as proposed by Doupe and colleagues [14]. We evaluated ED resource utilization, such as imaging and the proportion of visits that resulted in hospitalization. Additionally, we examined the nature of the ED visits to determine the frequency of primary care treatable conditions [14].

Methods

Study setting

We conducted a retrospective chart review of Medicaid enrollees with 4 or more ED visits from January 2011 through December 2011. This was a single-center study of patients seen in the ED of Yale-New Haven Hospital, or an affiliated satellite ED. The study was approved by the Yale University School of Medicine Institu- tional Review Board.

Definition of frequent users

We defined frequent ED users as patients who had at least 4 ED visits in the past year not resulting in a hospitalization. We used at least 4 ED visits, as this is the most commonly used definition of a frequent user [1,2,15].

Chart abstraction

We identified 1619 patients with Medicaid insurance who had 4 or more ED visits during the study period. We obtained administra- tive records to determine the number of ED visits, primary ED diagnosis, number of hospitalizations, and imaging utilization.

Chart reviews were conducted by 2 investigators, an emergency medicine attending (RC) and a research associate (CB), using a data abstraction protocol developed prior to initiation of medical record abstraction. The first 10 charts were independently reviewed by both investigators. The results were reviewed and discussed to ensure comparability and to resolve any ambiguities and discrepancies. An additional 100 charts were reviewed separately, but with both abstracters working side by side in case questions or discrepancies were noted. The remainder of the chart abstraction was performed separately. We abstracted the following data from each ED visit: ED diagnosis; presence of chronic medical conditions, psychiatric disorders, and alcohol and drug abuse; chronic medications; whether the patient has a primary care provider; and whether the patient left the ED without being seen (LWBS) by a clinician or against medical advice (AMA).

Based on the work of Doupe and colleagues, we categorized patients into 3 groups by number of ED visits: 4-6, 7-17, and >=18 visits [14].

Chronic diseases and primary ED diagnosis

We identified the primary ED discharge diagnosis using electronic billing data. We applied the Agency for Healthcare Research and Quality’s Clinical Classification Software, which combines multiple ICD-9 codes into Clinically meaningful catego- ries of conditions [16]. We identified the top 10 ED Clinical Classification Software categories found in each of the frequent ED user visit groups.

We systematically identified a subset of chronic diseases, including

(1) chronic obstructive pulmonary disease (COPD) or asthma, (2) hypertension, (3) coronary artery disease, (4) renal disease, (5) end- stage renal disease requiring dialysis, (6) diabetes, (7) HIV/AIDS, (8)

cancer, (9) hepatitis or cirrhosis, and (10) congestive heart failure [17]. We defined patients as having one of the above chronic illnesses if the given condition was documented on at least two separate visits, or if the patient’s medication list included a treatment related to the medical condition (eg, insulin in patient with diabetes). Chronic medications were defined as those that need to be taken on a regular basis (eg, insulin).

Psychiatric conditions and alcohol and drug abuse

We categorized patients as having a psychiatric disease if there was documentation of a given disorder on at least two separate visits. Alcohol abuse (defined as consuming more than 2 alcoholic drinks per day or self-report of alcohol abuse or dependence) and illicit drug use (eg, cocaine or crack, heroin or other opioids, and phencyclidine [PCP]) were abstracted if noted on at least two separate visits.

Living situation, discharge disposition, and access to primary care

We identified homelessness if this information was documented in at least one ED visit. We documented the patient’s disposition on discharge, including whether they were discharged home, admitted to the hospital, LWBS, of left AMA.

We identified the patient’s primary care provider or Primary care clinic if present in at least one ED visit. If no documentation of a primary care provider or primary care clinic was made in any of the ED visits, then the patient was categorized as having no primary care provider.

Analysis

Descriptive statistics were used to calculate mean, median, interquartile ranges (IQR), and percentages. We compared patient characteristics across ED frequency groups using chi-squared analyses for categorical variables and ANOVA for continuous variables. All statistics were performed using SAS 9.2 (SAS Institute, Inc, Cary, NC).

Results

Sample characteristics

Of the 13,959 Medicaid enrollees who visited the ED at least once during 2011, 1619 (12%) were frequent ED users. Of 27,169 ED visits by Medicaid enrollees in 2011, frequent ED users accounted for 10,337 ED visits, or 38% of all ED visits made by patients with Medicaid. Among Medicaid-enrolled frequent ED users, 1165 (72%) were in the 4-6 visits group, 416 (26%) were in the 7-17 visits group, and 38 (2%) were in the >=18 visits group. Overall, increasing frequency of ED use was significantly associated with older age, male sex, homelessness, lack of a primary care provider, and leaving the ED without being seen or against medical advice (Table 1).

Chronic diseases and mental health

As the results in Table 1 show, a total of 67% of patients had a primary care provider and 56% of patients had one or more chronic diseases. The most common chronic diseases among all frequent ED users included COPD/asthma (27%), hypertension (26%), and diabetes (13%) (Table 1). With the exception of coronary artery disease, there was no consistent pattern between prevalence of chronic condition and increasing frequency of ED use (Table 1).

The most common psychiatric diseases identified in frequent ED users were depression and/or anxiety (22%). Approximately one-third (31%) of all frequent users were taking a psychiatric medication (Table 2). Patients in the 7-17 visits group (45%) were more likely to have a psychiatric condition than were patients in the 4-6 (32%) and

Table 1

Characteristics of Medicaid enrollee frequent ED usersa

Characteristics

Total visits

%

4-6 Visits

%

7-17 Visits

%

>=18 Visits

%

P

(N = 1619)

(N = 1165, 72%)

(N = 416, 26%)

(N = 38, 2%)

Age

38 (IQR 28-49)b

36 (IQR 28-48)b

42 (IQR 30-50)b

45 (IQR 32-50)b

P b .05

Sex

Male

719

44%

481

41%

213

51%

25

66%

P b .05

Female

900

56%

684

59%

203

49%

13

34%

Race

White

545

34%

382

33%

150

36%

13

34%

P = .49

Black

693

43%

505

43%

168

40%

20

53%

Hispanic

344

21%

253

22%

86

21%

5

13%

Other

37

2%

25

2%

12

3%

0

0%

Chronic disease

COPD/asthma

431

27%

305

26%

119

29%

7

18%

P = .33

Hypertension

422

26%

278

24%

133

32%

11

29%

P b .05

Coronary artery disease

88

5%

52

4%

32

8%

4

11%

P b .05

Diabetes

215

13%

143

12%

65

16%

7

18%

P = .14

Renal dialysis

44

3%

24

2%

20

5%

0

0

P b .05

On dialysis

6

0.4%

2

0.2%

4

1%

0

0

P = .07

HIV/AIDS

58

4%

38

3%

19

5%

1

3%

P = .45

Cancer

22

1%

15

1%

7

2%

0

0

P = .64

Congestive heart failure

18

1%

11

1%

6

1%

1

3%

P = .47

Hepatitis or cirrhosis

164

10%

96

8%

63

15%

5

13%

P b .05

Chronic medication use

Yes

854

53%

581

50%

248

60%

25

66%

P b .05

No

765

47%

584

50%

168

40%

13

34%

Primary care provider

Federally qualified health center

352

22%

239

21%

107

26%

6

16%

P = .06

Hospital based clinic

455

28%

329

28%

121

29%

5

13%

P = .11

Community private physician

274

17%

190

16%

78

19%

6

16%

P = .51

None

530

33%

407

35%

103

25%

20

53%

P b .05

Patients LWBSb or AMAb at least once

672

42%

419

36%

219

53%

34

89%

P b .05

Homelessness

181

11%

85

7%

80

19%

16

42%

P b .05

a Numbers may not sum to column totals and percentages may not sum to 100% due to rounding.

b Results shown as median and IQR between the 25th and 75th percentiles.

>=18 (39%) visits groups (P b .05). All ED visit groups had similar distributions of substance use, with the exception of alcohol abuse, which was most commonly found in patients with >=18 visits (42%), compared with patients in the 4-6 visits group (15%) and 7-17 visits group (25%) (P b .05).

Top 10 ED diagnoses

Patients in the 4-6 visits group accounted for 5418 (53%) of visits, while those in the 7-17 and >=18 visits groups accounted for 3841 (37%) and 1078 (10%) of visits, respectively. Table 3 describes the 10 most common primary ED discharge diagnoses for all frequent users,

as well as for each visit group. Among the 4-6 visits group, no one diagnosis accounted for the majority of visits. Rather, the three most common diagnoses were abdominal pain (7%), back problem (5%), and chest pain (5%). Alcohol related visits were the most common primary ED diagnosis for visits made by the 7-17 and >=18 visits groups. Sickle cell disease accounted for 14% of all primary ED diagnoses among patients with >=18 visits (Table 3).

Discussion

In this study, 12% of Medicaid enrollees who utilized the ED were considered frequent ED users, accounting for nearly 40% of all ED visits

Table 2

Mental health and substance use characteristics of Medicaid enrollee frequent ED users

Total

%

4-6 Visits

%

7-17 Visits

%

>=18 Visits

%

P

N = 1619 (100%)

N = 1165 (72%)

N = 416 (26%)

N = 38 (2%)

Psychiatric conditions Any psychiatric Condition

570

35%

369

32%

186

45%

15

39%

P b .05

Depression or anxiety

350

22%

225

19%

116

28%

9

24%

P b .05

Bipolar

165

10%

96

8%

64

15%

5

13%

P b .05

Schizophrenia

69

4%

42

4%

27

6%

0

0%

P b .05

Other

49

3%

31

3%

17

4%

1

3%

P = .34

Psychiatric medication use

500

31%

322

28%

167

40%

11

30%

P b .05

Substance use

Cocaine/crack

169

11%

114

10%

51

12%

4

11%

P = .34

Heroin/opiods

66

4%

52

4%

12

3%

2

5%

P = .35

PCP

77

5%

51

4%

23

6%

3

8%

P = .42

Alcohol abuse

295

18%

174

15%

105

25%

16

42%

P b .05

Patients with ED use for psychiatric

567

35%

343

29%

198

48%

26

68%

P b .05

condition or substance use in 2010-2011

Table 3

Top 10 ED diagnoses of Medicaid enrollee frequent ED users, by number of ED visits

Total

Frequency

%

4-6 Visits

Frequency

%

7-17 Visits

Frequency

%

>=18 Visits

Frequency

%

Total number of ED visits

Alcohol related

10,337 (100%)

1030

10%

Abdominal pain

5418 (53%)

390

7%

Alcohol related

3841 (37%)

410

11%

Alcohol related

1078 (10%)

391

36%

disorders

Abdominal pain

680

7%

Back problem

276

5%

disorders

Abdominal pain

250

7%

disorders

Sickle cell

149

14%

Back problem

534

5%

Chest pain

250

5%

Back problem

238

6%

Chest pain

68

6%

Chest pain

Substance related

483

367

5%

4%

Alcohol related disorders

skin infection

229

201

4%

4%

Substance

related disorders Chest pain

172

165

5%

4%

Abdominal pain

Other joint

40

30

4%

3%

disorders

Other connective

326

3%

Substance

185

3%

Other after care

131

3%

disease

Substance

30

3%

tissue

Skin infection

322

3%

related disorders

Other connective

180

3%

Other connective

117

3%

related disorders

Other connective

29

3%

Other after care

319

3%

tissue

Sprain

177

3%

tissue

Superficial injury

114

3%

tissue

Epilepsy/central

26

2%

Sprain

300

3%

Other after care

176

3%

Skin infection

113

3%

nervous system

Unclassified

23

2%

Superficial injury

277

3%

Headache/ migraine

147

3%

Sprain

108

3%

Superficial injury

22

2%

made by patients with Medicaid. We found that two-thirds of Medicaid enrollee frequent ED users had a primary care provider. Patient characteristics differed by the number of ED visits. Most patients with 4-6 visits in one year had a chronic illness, although they presented to the ED for low acuity reasons that may potentially have been managed by a primary care provider. In the higher visit groups, however, alcohol and substance use disorders were related to the majority of visits. Interestingly, among patients in all visit groups, psychiatric illness was common, though was not the primary reason for the visit. These data suggest that interventions to reduce ED utilization among the Medicaid population need to be tailored; improving Primary care access, and addressing psychiatric and alcohol/substance use disorders may be effective.

Our study of Medicaid enrolled frequent ED users shows some similar findings to previous studies investigating frequent ED users. For example, regardless of insurance status, most frequent ED users have a primary care provider. There is also a high burden of mental illness among the very high ED utilizer groups [3,18]. Doupe and colleagues found that frequent ED users with >=18 ED visits were more likely than all other frequent ED users to have a mental illness; in our study, patients with 7-17 ED visits were more likely to have a mental illness when compared with all other Medicaid enrolled frequent ED users [14]. Furthermore, Doupe and colleagues found that patients with 18 or more ED visits per year were less likely to have a chronic medical condition than were other frequent ED users [14]. In contrast, our study shows the prevalence of chronic disease was similar for all visit groups with the exception of hepatitis/cirrhosis, which was more commonly found in patients who visited the ED more than 18 times per year. There is concern that frequent ED users seek care at the ED for conditions that can be treated in the primary care Outpatient setting. There is also a commonly held perception that frequent ED users are seeking narcotics, are homeless and looking for shelter, or presenting to the ED with alcohol related complaints [19]. In our study, patients with 18 or more ED visits per year were more likely to be homeless and not have a primary care provider; over one-third of their ED visits were made because of alcohol related disorders. However, this subgroup of patients represented a small fraction of the frequent ED user population. ED visits related to alcohol disorders were present in less than 10% of all ED visits among Medicaid enrollees who had less than

18 ED visits per year.

As policy makers and state officials design programs to decrease ED utilization among frequent ED users, our data may be helpful in a number of ways. For example, in our study we

found that 60% of patients with Medicaid identified a primary care physician. Moreover, with more than 18 ED visits per year were more likely to suffer from homelessness and not have a identifiable primary care physician. Medicaid patients typically experience multiple barriers to care (eg, longer wait-times to appointments, lack of transportation, etc); therefore, interventions designed to prevent ED use for primary care treatable conditions require more than just ensuring that patients have an identified primary care provider [12]. These patients also have complex social needs that may influence their use of the emergency department, such as patients who suffer from homelessness.

This study should be interpreted in the context of some limitations. This is a single center study, and thus reflects the local practices and patient population. Furthermore, we may have underestimated ED utilization, as the literature indicates that 58% of frequent ED users (defined as 5 or more visits) used more than 1 ED [2]. In restricting our definition of frequent ED users to patients with at least 4 ED visits that did not result in hospitalization, we may have selected a subgroup that is healthier than the larger population of Medicaid enrollees with frequent ED and hospital use. We intentionally used this restricted definition of frequent ED users in order to investigate a subgroup that may be more amenable to outpatient in- terventions. Additionally, we may have underestimated Disease burden, as patients were not systematically queried about all Disease states. Furthermore, it is possible that we may have underestimated the number of patients with a primary care physician as patients with low acuity conditions may not have been asked if they had a primary care doctor. We did have an alternative blinded abstractor to evaluate the reliability of data collection, but followed a standard protocol in the abstraction of the data. Finally, as this was a retrospective chart review, we were unable to assess the patient’s perspective, or other factors that may have led to frequent ED use. While this study provides the largest and most comprehensive data about Medicaid enrolled frequent ED users, prospective studies are needed.

Conclusion

Among Medicaid enrollees who visit the ED, one in eight are frequent ED users, accounting for 38% of all ED visits made by Medicaid patients. Several socio-demographic and clinical character- istics differed by frequency of ED visits made in 1 year. Patients with 4-6 ED visits per year were more likely to have a primary care provider. These patients may suffer from barriers in accessing

outpatient care services. Patients with >=18 ED visits per year were more likely than other patients to suffer from homelessness, alcohol abuse, and not have a primary care provider. Efforts to reduce frequent ED use among Medicaid enrollees should include improved access to and use of Primary care settings. More comprehensive health service interventions may be needed for patients with18 ED visits or more per year.

References

  1. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med 2006;48(1):1-8.
  2. Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med 2006;48(1):9-16.
  3. Sun BC, Burstin HR, Brennan TA. Predictors and outcomes of frequent emergency department users. Acad Emerg Med 2003;10(4):320-8.
  4. Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med 2000;7(6):637-46.
  5. Sandoval E, Smith S, Walter J, et al. A comparison of frequent and infrequent visitors to an urban emergency department. J Emerg Med 2010;38(2):115-21.
  6. Pines JM, Asplin BR, Kaji AH, et al. Frequent users of emergency department services: gaps in knowledge and a proposed research agenda. Acad Emerg Med 2011;18(6):e64-9.
  7. Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004;42(2):176-82.
  8. Brenner J. Camden coalition program. http://www.camdenhealth.org/ wp-content/uploads/2011/01/Charges-Hotspots.pdf; 2012. Accessed August 09,

    2012.

    Fehrenbacher AH, Robin; Wilkinson, Becky. ED Diversion: Multi-Disciplinary Approach Engages high utilizers, Helps them Better Navigate the Health Care System. ED Management 2011.

  9. Foundation KF. Characteristics of frequent emergency department users. http:// www.kff.org/insurance/upload/7696.pdf. Accessed August 09, 2012.
  10. Kne T, Young R, Spillane L. Frequent ED users: patterns of use over time. Am J Emerg Med 1998;16(7):648-52.
  11. Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficia- ries. Ann Emerg Med 2012;60(1):4-10 e12.
  12. Lowe RA, Fu R, Ong ET, et al. Community characteristics affecting emergency department use by Medicaid enrollees. Med Care 2009;47(1):15-22.
  13. Doupe MB, Palatnick W, Day S, et al. Frequent users of emergency departments: developing standard definitions and defining prominent risk factors. Ann Emerg Med 2012;60(1):24-32.
  14. Cook LJ, Knight S, Junkins Jr EP, Mann NC, Dean JM, Olson LM. Repeat patients to the emergency department in a statewide database. Acad Emerg Med 2004;11(3): 256-63.
  15. Clinical Classifciation Software (CCS) for ICD-9 CM. 2012.
  16. Iezzoni LI, Heeren T, Foley SM, Daley J, Hughes J, Coffman GA. Chronic conditions and risk of in-hospital death. Health Serv Res 1994;29(4):435-60.
  17. Bieler G, Paroz S, Faouzi M, et al. Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system. Acad Emerg Med 2012;19(1):63-8.
  18. Quinones S. Saving the ER for real emergencies: costly “frequent fliers” are being encouraged to visit clinics in LA. Lost Angeles Times, January 22, 2007.

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