HOUSTON AREA HOSPITALS EMERGENCY DEPARTMENT USE STUDY

January 1, 2006 through December 31, 2006

Prepared By

University of Texas School of Public HealthHouston Health Services Research Collaborative

Final ReportApril 3, 2008

Monitor trends in ER use in Houston hospitals Determine primary care related use

Describe characteristics of patients with PCR use Map the distribution of patients with PCR use

Surveyed 37 Houston area hospitals with “public” ERs (receive 911 ambulance transports from the Houston Fire Department and walk-ins from the general population)

Requested 9 data elements on all 2006 ED visits

Checked the data for consistency and completeness

Applied the NYU Algorithm to identify primary care related visits

Analyzed the characteristics of patients with PCR visits

Two - Harris County Hospital District Ben Taub General and Lyndon B. Johnson General

Nine - Memorial Hermann Health Care System Hermann/Texas Medical Center, Southwest, Southeast, Northeast, Northwest, The Woodlands,

Memorial City, Katy, Sugar Land

Four - Hospital Corporation of America Bayshore Medical Center, Spring Branch, East Houston Regional, West Houston

St. Joseph Medical Center

River Oaks Hospital

Texas Children’s Hospital

Two - CHRISTUS Gulf Coast Hospitals St. Catherine and St. John

Two - St. Luke’s Hospitals Episcopal and Community Medical Center

Three - Methodist Hospital System Texas Medical Center, San Jacinto, Willowbrook

Houston Community Hospital

Methodist Hospital Sugar Land

Doctors Hospitals Tidwell Parker

Four - HCA Hospitals Clear Lake Regional Medical Center Kingwood Medical Center Conroe Medical Center Mainland Hospital

Tenet Hospitals Cypress Fairbanks Medical Center Houston Northwest Medical Center Park Plaza Hospital

Tomball Regional Hospital

Date and time of admission to ED Primary and secondary discharge diagnosis Discharge date and time Payment source Patient age Patient gender Patient race/ethnicity Patient ZIP code Where discharged to (e.g. hospital, home, nursing home, etc.)

NYU ALGORITHM NYU ALGORITHM

Emergent

Primary Care Treatable

ED Care Needed

Not preventable/avoidable

Preventable/avoidable

Non-Emergent

1. Non-emergent: Treatment not required within 12 hours.

2. Emergent-Primary Care Treatable: Treatment required within 12 hours, but could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting.

3. Emergent-ED Care Needed-Preventable/Avoidable: ER treatment required within 12 hours, but the condition was potentially preventable/avoidable if timely primary care had been received (flare-ups of asthma, diabetes, congestive heart disease, etc.) (early intervention prevention of ENT infections, cellulitis, pneumonia, immunization preventable illness, etc.)

4. Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required within 12 hours and primary care could not have prevented the condition.

991,861 ED visits were made to these 25 hospitals in 2006. Represents about 76.0% of the 1.3 million ED visits to

Harris County hospitals

780,076 ED visits (78.6%) were non hospitalized

709,496 non hospitalized ED visits were made by Harris County residents This represents 91.0% of total non hospitalized ED

visits.

Type of Visit All

Number 25

CATEGORIZED VISITSNon-Emergent 146,963Emergent, Primary Care Treatable 162,192Emergent, ED Care Needed - Preventable/Avoidable 56,800

Total Primary Care Related Visits 365,955Emergent, ED Care Needed - NOT Preventable/Avoidable 82,485

Total Categorized Visits 448,440NON-CATEGORIZED VISITS

Injury 166,872Mental Health Related 10,466Alcohol or Drug Related 5,297Unclassified 78,421

Total Non-Categorized Visits 261,056Total Visits 709,496

Percent

CATEGORIZED VISITSNon-Emergent 32.8%Emergent - Primary Care Treatable 36.2%ED Care Needed - Prev./Avoid. 12.7%

% Total Primary Care Related 81.6%ED Care Needed - NOT Prev./Avoid. 18.4%

TOTALNon-Emergent 20.7%Emergent - Primary Care Treatable 22.9%ED Care Needed - Prev./Avoid. 8.0%

% Total Primary Care Related 51.6%ED Care Needed - NOT Prev./Avoid. 11.6%

% Categorized ED Visits 63.2%Injury 23.5%Mental Health Related 1.5%Alcohol or Drug Related 0.7%Unclassified 11.1%

% All Visits 100.0%

The Medical Expenditure Panel Survey (MEPS), conducted by the federal Agency for Healthcare Research and Quality, found that in 2003 (the most recent year for national estimates) the mean cost of an ED visit was $560, whereas the mean cost of an office-based physician visit was $121.

In 2006, 118,689 PCR ED visits by Harris County area residents were by persons who were uninsured. Using the MEPS estimates, the estimated cost of those visits was $66,465,840. If those same visits had taken place in an office based setting, the estimated cost would have been $14,361,369 – a savings of over $50,000,000 to the community.

31.2% 33.0%25.7%

31.2%

44.4%35.8% 32.8%

36.0%39.3%

31.6%

34.8%

31.1%35.9%

36.2%

11.4%14.0%

17.0%

12.7%

7.5% 11.8% 12.7%

21.3%13.7%

25.7% 21.3% 16.9% 16.5% 18.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Emergent Care Needed-NOT Preventable/AvoidableEmergent Care Needed-Preventable/AvoidableEmergent-Primary Care TreatableNon-Emergent

33.1% 33.7%25.1%

32.8%

40.7%34.1%

31.2%

36.2%

14.2%

11.1%

16.4%

12.7%

11.9%21.1%

27.3%18.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0-17 18-64 65+ All

Emergent Care Needed-NOT Preventable/AvoidableEmergent Care Needed-Preventable/AvoidableEmergent-Primary Care TreatableNon-Emergent

Obs Icd COUNT Description

1 4659 18,247 acute uri nos2 3829 14,870 otitis media nos3 7806 13,069 fever4 5589 12,277 noninf gastroenterit nec5 5990 12,137 urin tract infection nos6 462 10,220 acute pharyngitis7 486 8,744 pneumonia, organism nos8 7840 8,644 headache9 49392 7,599 asthma nos w(ac) exacerb

10 78039 7,438 convulsions nec11 78900 7,348 abdmnal pain unspcf site12 6826 6,718 cellulitis of leg13 78703 6,143 vomiting alone14 4019 5,810 hypertension nos15 78659 5,684 chest pain nec16 7999 5,532 viral infection nos17 64893 5,142 oth curr cond-antepartum18 7242 5,067 lumbago19 490 5,039 bronchitis nos20 7804 4,741 dizziness and giddiness21 7295 4,642 pain in limb22 4660 4,554 acute bronchitis23 V642 4,322 no proc/patient decision24 78652 3,848 painful respiration25 64003 3,477 threaten abort-antepart

Obs Icd COUNT Description

1 78650 5,903 chest pain nos2 78900 3,623 abdmnal pain unspcf site3 78659 3,617 chest pain nec4 7802 3,365 syncope and collapse5 7806 3,187 fever6 5921 3,012 calculus of ureter7 5920 1,803 calculus of kidney8 64003 1,739 threaten abort-antepart9 78909 1,580 abdmnal pain oth spcf st

10 V715 1,536 observ following rape11 5409 1,471 acute appendicitis nos12 7851 1,329 palpitations13 78703 1,316 vomiting alone14 7840 1,290 headache15 4644 1,226 croup16 42731 1,219 atrial fibrillation17 5770 1,198 acute pancreatitis18 46619 1,149 acu brnchlts d/t oth org19 57420 1,087 cholelithiasis nos20 4359 1,074 trans cereb ischemia nos21 53550 1,048 gstr/ddnts nos w/o hmrhg22 56211 1,028 dvrtcli colon w/o hmrhg23 28262 942 hb-s disease with crisis24 78906 878 abdmnal pain epigastric25 5789 829 gastrointest hemorr nos

Type of Visit 2002 2003 2004 2005* 2006*

Number 11 11 11 11 11

CATEGORIZED VISITS

Non-Emergent 103,205 110,722 101,965 76,487 70,175Emergent, Primary Care Treatable 103,377 109,885 93,447 74,034 70,544Emergent, ED Care Needed - Preventable/Avoidable 36,371 38,340 28,229 22,679 25,230

Total Primary Care Related Visits 242,953 258,947 223,641 173,200 165,948

Emergent, ED Care Needed - NOT Preventable/Avoidable 55,293 57,130 44,108 34,515 39,516Total Categorized Visits 298,246 316,077 267,749 207,715 205,464

NON-CATEGORIZED ED VISITS

Injury 107,025 109,032 92,884 73,472 72,587Mental Health Related 7,660 7,901 7,762 5,694 5,266Alcohol or Drug Related 4,107 3,854 3,446 2,757 3,261Unclassified 48,871 49,018 36,358 30,598 32,198

Total Non-Categorized Visits 167,663 169,805 140,450 112,521 113,312

Total Visits 465,909 485,882 408,199 320,236 318,776

Percent

DETAIL - CATEGORIZED ED VISITS

Non-Emergent 34.6% 35.0% 38.1% 36.8% 34.2%

Emergent - Primary Care Treatable 34.7% 34.8% 34.9% 35.6% 34.3%

ED Care Needed - Prev./Avoid. 12.2% 12.1% 10.5% 10.9% 12.3%

% Primary Care Related Visits 81.5% 81.9% 83.5% 83.4% 80.8%

ED Care Needed - NOT Prev./Avoid. 18.5% 18.1% 16.5% 16.6% 19.2%

TOTAL ED VISITS

Non-Emergent 22.2% 22.8% 25.0% 23.9% 22.0%

Emergent - Primary Care Treatable 22.2% 22.6% 22.9% 23.1% 22.1%

ED Care Needed - Prev./Avoid. 7.8% 7.9% 6.9% 7.1% 7.9%

% Primary Care Related Visits 52.1% 53.3% 54.8% 54.1% 52.1%

ED Care Needed - NOT Prev./Avoid. 11.9% 11.8% 10.8% 10.8% 12.4%

% Categorized ED Visits 64.0% 65.1% 65.6% 64.9% 64.5%

Injury 23.0% 22.4% 22.8% 22.9% 22.8%

Mental Health Related 1.6% 1.6% 1.9% 1.8% 1.7%

Alcohol or Drug Related 0.9% 0.8% 0.8% 0.9% 1.0%

Unclassified 10.5% 10.1% 8.9% 9.6% 10.1%

% All Visits 100.0% 100.0% 100.0% 100.0% 100.0%

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

2002

2003

2004

2005

2006

What has not changed?

1) More than 5 out of 10 non-hospitalized ED visits and 8 out of 10 categorized ED visits are primary care related.

2) The peak time for total ED visits and primary care related ED visits is the middle of the day. This is a time at which outpatient clinics would normally be open.

3) Almost 60% of primary care related ED visits are by those who are uninsured or have Medicaid coverage.

4) Roughly two out of three primary care related ED visits are by persons who are Black or Hispanic.

5) Just under four out of ten primary care related ED visits are by children age 17 or younger, and almost 60% of primary care related ED visits are by females.

6) The geographical concentrations of patients with the highest rates primary care related ED visits is in low-income areas of the County.

What has changed?

1) The total number of non-hospitalized visits has declined over the last three years.

2) The percentage that are primary care related has come down slightly in the last three years.

3) The four-year trend in payer mix of more primary care related ED visits by the uninsured and fewer privately insured has ended.