Milken Institute School of Public Health Poster Presentations (Marvin Center & Video)

Title

Role of Social and Clinical Determinants in Frequent Utilization of Emergency Departments

Poster Number

90

Document Type

Poster

Status

Graduate Student - Doctoral

Abstract Category

Health Policy and Management

Keywords

frequent utilization of ED, care continuity, social determinants of health

Publication Date

Spring 2018

Abstract

Objective: Frequent utilizers of EDs (FUEDs) utilize Emergency Department (ED) services at least four times/year, comprise less than 10% of ED patients but account for a quarter of ED visits. FUEDs comprise a high-cost-high-need vulnerable group of patients with multiple chronic diseases and poor health outcomes. Through application of the WHO CSDH Framework, this research sought to characterize the care utilization of FUEDs and elicit the influence of specific social and clinical determinants upon total and preventable ED utilization.

Study Design: Analysis of claims data merged with interview data from the George Washington University Hospital (GWUH) Frequent User Study was used in a retrospective cohort study design. We applied negative binomial regression to estimate patient level effects upon (i) total ED visits (ii)preventable ED visits. Independent variables included indicators of social and clinical determinants.

Population Studied: 474 DC Medicaid beneficiaries, 18-64 years, who attended GWUH between October 2015 – 2016 and attended any ED 3 or more times in the past 1 year.

Principal Findings: In one year, FUEDs had an average of 16.2 total ED visits and 30% of ED visits were preventable. People with mental illness had more ambulatory care visits (mean 11, SD 9.3) compared to FUEDs without. 60% of FUEDs had a diagnosed mental illness but there was significant underutilization of psychiatric evaluation and management (mean 1.2, SD 4.4). Multivariate analyses revealed that increased physical illness severity, poor behavioral health status, inadequate food and shelter were associated with increased number of total and preventable ED visits. Increased levels of social support were associated with a decrease in total (IRR 0.94) and preventable (IRR 0.86) ED utilization. Physical illness severity and CC had a significant positive interaction effect upon ED utilization. FUEDs whose CC could not be assessed due to inadequate ambulatory care (<3 visits/year) had the greatest ED utilization.

Conclusion: Addressing inadequate access to food and shelter and providing social support could reduce the number of preventable ED visits and further leverage the benefits due to care continuity in FUEDs with multiple physical and behavioral health conditions.

Policy Implications: This research is directly applicable to DC Medicaid Care Coordination initiatives whereby patients with multiple chronic illnesses can receive a care coordination benefit. Curbing ED use by FUEDs will require a two-pronged approach: adequate and coordinated ambulatory care for those most at risk as well as attention to specific social determinants they experience.

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Role of Social and Clinical Determinants in Frequent Utilization of Emergency Departments

Objective: Frequent utilizers of EDs (FUEDs) utilize Emergency Department (ED) services at least four times/year, comprise less than 10% of ED patients but account for a quarter of ED visits. FUEDs comprise a high-cost-high-need vulnerable group of patients with multiple chronic diseases and poor health outcomes. Through application of the WHO CSDH Framework, this research sought to characterize the care utilization of FUEDs and elicit the influence of specific social and clinical determinants upon total and preventable ED utilization.

Study Design: Analysis of claims data merged with interview data from the George Washington University Hospital (GWUH) Frequent User Study was used in a retrospective cohort study design. We applied negative binomial regression to estimate patient level effects upon (i) total ED visits (ii)preventable ED visits. Independent variables included indicators of social and clinical determinants.

Population Studied: 474 DC Medicaid beneficiaries, 18-64 years, who attended GWUH between October 2015 – 2016 and attended any ED 3 or more times in the past 1 year.

Principal Findings: In one year, FUEDs had an average of 16.2 total ED visits and 30% of ED visits were preventable. People with mental illness had more ambulatory care visits (mean 11, SD 9.3) compared to FUEDs without. 60% of FUEDs had a diagnosed mental illness but there was significant underutilization of psychiatric evaluation and management (mean 1.2, SD 4.4). Multivariate analyses revealed that increased physical illness severity, poor behavioral health status, inadequate food and shelter were associated with increased number of total and preventable ED visits. Increased levels of social support were associated with a decrease in total (IRR 0.94) and preventable (IRR 0.86) ED utilization. Physical illness severity and CC had a significant positive interaction effect upon ED utilization. FUEDs whose CC could not be assessed due to inadequate ambulatory care (<3 visits>/year) had the greatest ED utilization.

Conclusion: Addressing inadequate access to food and shelter and providing social support could reduce the number of preventable ED visits and further leverage the benefits due to care continuity in FUEDs with multiple physical and behavioral health conditions.

Policy Implications: This research is directly applicable to DC Medicaid Care Coordination initiatives whereby patients with multiple chronic illnesses can receive a care coordination benefit. Curbing ED use by FUEDs will require a two-pronged approach: adequate and coordinated ambulatory care for those most at risk as well as attention to specific social determinants they experience.