Dataset Information

Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?

ABSTRACT:

Objective

To examine the contributions of individual- and neighborhood-level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures.

Data sources/study setting

Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago.

Study design

Multilevel logit regression was used to model the relationship between individual- and neighborhood-level attributes and preventable ED use.

Data collection/extraction methods

Emergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes.

Principal findings

Beyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use.

Conclusions

Preventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.

SUBMITTER: Fishman J

PROVIDER: S-EPMC5785320 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?

Fishman Jamie J McLafferty Sara S Galanter William W

Health services research 20161117 1

<h4>Objective</h4>To examine the contributions of individual- and neighborhood-level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures.<h4>Data sources/study setting</h4>Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the ...[more]

PMID: 27859257

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Project description:ImportanceMonitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care.ObjectivesTo identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization.Design, setting, and participantsA modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018.Main outcomes and measuresIdentification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges.ResultsAn expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P < .001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P < .001).Conclusions and relevanceThis comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.

Project description:BackgroundAs the number of patients with nonemergent conditions who are transported by paramedics continues to increase in Ontario, redirecting specific patients to subacute settings may be more beneficial and suitable for both patients and emergency departments. We aimed to evaluate whether emergency department interventions conducted on patients with nonemergent conditions who are transported by paramedics could be conducted in subacute health centres.MethodsWe conducted a RAND/UCLA modified Delphi study in Ontario between Oct. 13 and Dec. 19, 2020. We used purposive sampling to recruit practising emergency and primary care physicians for an expert panel. We abstracted interventions given to adult patients with nonemergent conditions (18 yr of age or older) who were transported by paramedics to an emergency department from the National Ambulatory Care Reporting System (NACRS) database (Jan. 1, 2014, to Mar. 31, 2018). Participants in the expert panel rated the suitability of the 150 most frequently recorded emergency department interventions from the NACRS database, for completion in subacute health care centres. We set consensus at 70% agreement.ResultsWe invited 25 physician experts, 21 of whom consented to participate; 20 physicians completed round 1, and 18 physicians completed both rounds. After 2 rounds, consensus was reached on 146 (97.3%) interventions; 103 interventions (68.7%) were suitable for subacute centres, 43 (28.7%) for only the emergency department and 4 (2.6%) did not receive consensus. For subacute centres, all 103 interventions were rated for urgent care centres; walk-in medical centres were applicable for 46 (30.6%) interventions and clinics led by nurse practitioners for 47 (31.3%) interventions.InterpretationMost interventions provided to patients with nonemergent conditions transported by paramedics to emergency departments were identified as suitable for urgent care clinics, with one-third being suitable for either walk-in medical centres or clinics led by nurse practitioners. This study has potential to inform a patient classification model for paramedic-initiated redirection of patients from emergency departments, although further contextualization is required for this to be implemented in clinical practice.Study registrationID ISRCTN22901977.

Project description:Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care.The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Project description:BACKGROUND:Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. METHODS:This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. RESULTS:Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR] = 1.61, 95% confidence interval [CI] = 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR = 1.49, 95% CI = 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR = 1.10, 95% CI = 1.04 to 1.16) and hospitalizations (IRR = 1.10, 95% CI = 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates. CONCLUSIONS:Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

Dataset Information

Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?

Objective

Data sources/study setting

Study design

Data collection/extraction methods

Principal findings

Conclusions

Publications

Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?

Similar Datasets

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