Dataset Information

Short-term Outcomes for Medicare Beneficiaries After Low-acuity Visits to Emergency Departments and Clinics.

ABSTRACT: There is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers.To compare illness severity between patients visiting EDs and outpatient clinics, by comparing short-term mortality and hospitalization, controlling for patient demographics, comorbidity, and visit acuity.Cross-sectional study of outcomes after medical encounters.Nationally representative 20% sample of Medicare fee-for-service beneficiaries discharged home from ED or clinic visit in 2011, and enrolled continuously for 1 year before the visit.All-cause mortality and hospitalization in the 8, 15, and 30 days after discharge home from ED or clinic visits.After risk-adjusting for patient demographic, comorbidity, disability, and dual-eligibility status, as well as visit acuity as measured by a commonly used algorithm, we found that ED patients were more likely to die (risk-adjusted odds ratio=2.75; 95% confidence interval, 2.56-2.96) or be hospitalized (odds ratio=1.97; 95% confidence interval, 1.95-2.00) after discharge than clinic patients. Differences in short-term outcomes were observed even when comparing patients with the same discharge diagnoses after risk adjustment.Patients presenting to EDs have worse risk-adjusted short-term outcomes than those presenting to outpatient clinics, even after controlling for acuity level of visit or discharge diagnosis. Existing measures of acuity using administrative data may not adequately capture severity of illness, making judgments of the appropriate setting for care difficult.

SUBMITTER: Niedzwiecki M

PROVIDER: S-EPMC4834890 | biostudies-literature | 2016 May

REPOSITORIES: biostudies-literature

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Short-term Outcomes for Medicare Beneficiaries After Low-acuity Visits to Emergency Departments and Clinics.

Niedzwiecki Matthew M Baicker Katherine K Wilson Michael M Cutler David M DM Obermeyer Ziad Z

Medical care 20160501 5

<h4>Background</h4>There is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers.<h4>Objective</h4>To compare illness severity between patients visiting EDs and outpatient clinics, by comparing short-term mortality and hospita ...[more]

PMID: 27078822

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Project description:BackgroundCanadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents' perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.MethodsWe conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.ResultsParents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child's problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).ConclusionsMany parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.

Project description:ObjectiveTo improve the performance of International Classification of Disease (ICD) code rule-based algorithms for identifying low acuity Emergency Department (ED) visits by using machine learning methods and additional covariates.Data sourcesWe used secondary data on ED visits from the National Hospital Ambulatory Medical Survey (NHAMCS), from 2016 to 2020.Study designWe established baseline performance metrics with seven published algorithms consisting of International Classification of Disease, Tenth Revision codes used to identify low acuity ED visits. We then trained logistic regression, random forest, and gradient boosting (XGBoost) models to predict low acuity ED visits. Each model was trained on five different covariate sets of demographic and clinical data. Model performance was compared using a separate validation dataset. The primary performance metric was the probability that a visit identified by an algorithm as low acuity did not experience significant testing, treatment, or disposition (positive predictive value, PPV). Subgroup analyses assessed model performance across age, sex, and race/ethnicity.Data collectionWe used 2016-2019 NHAMCS data as the training set and 2020 NHAMCS data for validation.Principal findingsThe training and validation data consisted of 53,074 and 9542 observations, respectively. Among seven rule-based algorithms, the highest-performing had a PPV of 0.35 (95% CI [0.33, 0.36]). All model-based algorithms outperformed existing algorithms, with the least effective-random forest using only age and sex-improving PPV by 26% (up to 0.44; 95% CI [0.40, 0.48]). Logistic regression and XGBoost trained on all variables improved PPV by 83% (to 0.64; 95% CI [0.62, 0.66]). Multivariable models also demonstrated higher PPV across all three demographic subgroups.ConclusionsMachine learning models substantially outperform existing algorithms based on ICD codes in predicting low acuity ED visits. Variations in model performance across demographic groups highlight the need for further research to ensure their applicability and fairness across diverse populations.

Project description:BACKGROUND:Few studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization. METHODS:Data came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits. RESULTS:The percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12-12.59%, 14.15-19.03%, and 76.61-80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21-1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57-0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14-2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43-2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56-0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79-7.89) and ER admissions (OR = 3.63, 95% CI = 2.88-4.57) than participants who survived at least three-years. CONCLUSION:We observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

Project description:ObjectiveTo characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low-acuity emergency department (ED) visits.Data sourcesPublicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).Study designWe systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low-acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreements using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low-acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference.Data collectionWe used the 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk.Principal findingsWe identified 15 papers with an original list of ICD codes used to identify preventable or low-acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization.ConclusionsExisting algorithms that identify low-acuity ED visits lack congruence and are imperfect predictors of visit acuity.

Project description:ImportanceRural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).ObjectiveTo compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.Design, setting, and participantsThis propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.Main outcomes and measuresThe primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.ResultsThe matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.Conclusions and relevanceThe findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Project description:Background: Healthcare spending for coronary artery disease (CAD)-related services is higher than for other chronic conditions. Diagnosis of incident cancer may impede management of CAD, thereby increasing the risk of CAD-related complications and associated healthcare expenditures. This study examined the relationship between incident cancer and CAD-related expenditures among elderly Medicare beneficiaries. Patients and Methods: A retrospective longitudinal study was conducted using the SEER-Medicare linked registries and a 5% noncancer random sample of Medicare beneficiaries. Elderly fee-for-service Medicare beneficiaries with preexisting CAD and with incident breast, colorectal, or prostate cancer (N=12,095) or no cancer (N=34,237) were included. CAD-related healthcare expenditures comprised Medicare payments for inpatient, home healthcare, and outpatient services. Expenditures were measured every 120 days during the 1-year preindex and 1-year postindex periods. Adjusted relationship between incident cancer and expenditures was analyzed using the generalized linear mixed models. Results: Overall, CAD-related mean healthcare expenditures in the preindex period accounted for approximately 32.6% to 39.5% of total expenditures among women and 41.5% to 46.8% among men. All incident cancer groups had significantly higher CAD-related expenditures compared with noncancer groups (P<.0001). Men and women with colorectal cancer (CRC) had 166% and 153% higher expenditures, respectively, compared with their noncancer counterparts. Furthermore, men and women with CRC had 57% and 55% higher expenditures compared with those with prostate or breast cancer, respectively. Conclusions: CAD-related expenditures were higher for elderly Medicare beneficiaries with incident cancer, specifically for those with CRC. This warrants the need for effective programs and policies to reduce CAD-related expenditures. Close monitoring of patients with a cancer diagnosis and preexisting CAD may prevent CAD-related events and expenditures.

Dataset Information

Short-term Outcomes for Medicare Beneficiaries After Low-acuity Visits to Emergency Departments and Clinics.

Publications

Short-term Outcomes for Medicare Beneficiaries After Low-acuity Visits to Emergency Departments and Clinics.

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