Characteristics of Medicaid enrollees with frequent ED use

doi:10.1016/j.ajem.2013.05.050

The American Journal of Emergency Medicine

Volume 31, Issue 9, September 2013, Pages 1333-1337

https://doi.org/10.1016/j.ajem.2013.05.050 Get rights and content

Abstract

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 < .05) and suffer from alcohol abuse (15% vs 42%, P < .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.

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 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 sociodemographic 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 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].

Section snippets

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 Institutional 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

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

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 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

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 characteristics 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

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Cited by (49)

The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York
2021, Journal of Emergency Medicine
Citation Excerpt :
Beyond the effect of the Medicaid expansion, the results also indicate that frequent use is consistently associated with Medicaid coverage compared with private insurance or lack of coverage, and more than 65% of frequent ED patients were covered by Medicaid over time in the data. Despite the observed decline in frequent use among Medicaid patients as a result of the policy implementation, these findings shed light on the continuous need to address social determinants of health with multilevel approaches beyond the individual patient (36–38). Coordination of care, which has been proven effective on mitigating frequent ED use and improved patients’ satisfaction and health outcomes coupled with patients’ and providers’ education, have to be adopted by Medicaid programs to better serve these high-need patients (20,39–42).
There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use.
To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York.
We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years.
Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95–0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86–0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08–1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years.
The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.
Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial
2020, Journal of Emergency Medicine
Citation Excerpt :
To facilitate development of the ED-initiated Patient Navigation program (ED-PN), we met with the leadership of our hospital primary care centers, ED, and two federally qualified community-based health clinics to solicit feedback on the intervention design and discuss mechanisms for program referrals and communication about shared patients. We also conducted a retrospective chart review of frequent ED users at the hospital to characterize the population and identify subpopulations that could benefit from patient navigation (18). In addition, we surveyed Medicaid-insured patients in our hospital ED to understand patient motivations and preferences for seeking care in the ED vs. a primary care setting (19).
Some Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.
To determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.
We conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4–18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.
Of 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (−$10,201, p = 0.10); Medicaid costs were unchanged (−$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).
An ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.
Commentary: Addressing the Challenges of the Homeless Patient
2019, Annals of Emergency Medicine
Substance use and homelessness among emergency department patients
2018, Drug and Alcohol Dependence
Homelessness and substance use often coexist, resulting in high morbidity. Emergency department (ED) patients have disproportionate rates of both homelessness and substance use, yet little research has examined the overlap of these issues in the ED setting. We aimed to characterize alcohol and drug use in a sample of homeless vs. non-homeless ED patients.
A random sample of urban hospital ED patients were invited to complete an interview regarding housing, substance use, and other health and social factors. We compared substance use characteristics among patients who did vs. did not report current literal (streets/shelter) homelessness. Additional analyses were performed using a broader definition of homelessness in the past 12-months.
Patients who were currently homeless (n = 316, 13.7%) versus non-homeless (n = 1,993, 86.3%) had higher rates of past year unhealthy alcohol use (44.4% vs. 30.5%, p < .0001), any drug use (40.8% vs. 18.8%, p < .0001), heroin use (16.7% vs. 3.8%, p < .0001), prescription opioid use (12.5% vs. 4.4%, p < .0001), and lifetime opioid overdose (15.8% vs. 3.7%, p < .0001). In multivariable analyses, current homelessness remained significantly associated with unhealthy alcohol use, AUDIT scores among unhealthy alcohol users, any drug use, heroin use, and opioid overdose; past 12-month homelessness was additionally associated with DAST-10 scores among drug users and prescription opioid use.
Patients experiencing homelessness have higher rates and greater severity of alcohol and drug use than other ED patients across a range of measures. These findings have implications for planning services for patients with concurrent substance use and housing problems.
Homelessness at discharge and its impact on psychiatric readmission and physician follow-up: A population-based cohort study
2019, Epidemiology and Psychiatric Sciences
Residential instability, including transience (i.e. unusually frequent mobility), is associated with higher risk for emotional and behavioural problems in children and young adults. However, most studies have not compared the effect of recent v. more distal moves on mental health or on mental health treatment. This study examined associations between recent (past year) and distal (past 2–4 years) residential transience and past year major depressive episode (MDE) and mental health treatment in a nationally representative sample of US adolescents aged 12–17.
Data are from the 2010–2014 National Surveys on Drug Use and Health (n = ~107 300 adolescents). T-tests were used to examine the prevalence of MDE by number of moves in the past 5 years among a nationally representative sample of adolescents. Additionally, multivariable logistic regression models were used to evaluate the adjusted association between recent (⩾2 moves in the past year) and distal (⩾4 moves in the past 5 years, but no recent transience) and (1) past year MDE and (2) past year mental health treatment among adolescents with MDE.
MDE prevalence increased linearly with number of moves in the past 5 years (p < 0.001). The adjusted odds of MDE were greater among youths with distal transience (adjusted odds ratio (AOR) = 1.25, 95% confidence interval (CI) = 1.09–1.44) and among those with proximal transience (AOR = 1.31, 95% CI = 1.17–1.46), compared with those without transience in the past 5 years. The MDE prevalence did not differ between those with distal and proximal transience (p = 0.163). In youths with past year MDE, the prevalence of past year mental health treatment was greater among those with proximal transience compared with those without transience (AOR = 1.40, 95% CI = 1.15–1.70), but there was no significant difference in treatment among those with distal v. no transience.
Distal and recent transience are associated with past year MDE among adolescents. Adolescents with MDE who had recent transience were more likely to receive past year mental health treatment compared with those without transience. However, those with only distal transience were not more likely to receive treatment. Parents, school officials and health care providers should be aware that residential mobility in the past 5 years may indicate increased odds of depression among adolescents even among adolescents whose housing stability has improved in the past year.
Understanding the surgical care needs and use of outpatient surgical care services among homeless patients at the Ottawa Hospital
2018, Canadian Journal of Surgery
The use of outpatient health care services by homeless people is low compared to their high level of need; however, it is unclear whether this applies to surgical care. We sought to describe surgical care access among homeless patients in a Canadian tertiary care setting.
We reviewed the medical records of adult (age > 18 yr) patients with no fixed address or a shelter address who presented to The Ottawa Hospital Emergency Department from Jan. 1, 2013, to Dec. 31, 2014, and required surgical referral. We analyzed the data using descriptive statistics.
A surgical referral was initiated in 129 emergency department visits for 97 patients (77 men [79%], mean age 46.7 yr). Most patients lived in shelters (77 [79%]) and had provincial health insurance (82 [84%]), but only 35 (36%) had a primary care physician. The mean number visits for any reason was 7.9 (standard deviation 13.7) (range 1–106). The majority of surgical referrals (83 [64.3%]) were for traumatic injuries, and the most frequently consulted service (52 [40.3%]) was orthopedic surgery. Just under half (48 [49%]) of referred patients attended at least 1 outpatient appointment, and only a third (33 [34%]) completed full follow-up.
Homeless patients presenting to an emergency department and requiring surgical care were predominantly men living in shelters, most frequently seeking care for traumatic injuries. Current outpatient services may not meet the surgical care needs of these patients, as many do not access them. Alternative approaches to outpatient care must be considered, particularly among high-need services such as orthopedics, to support surgical care access among this population.
L’utilisation des services de santé ambulatoires par les sans-abri est faible si on la compare à leurs besoins qui sont élevés; on ignore par contre s’il en va de même pour les soins chirurgicaux. Nous avons voulu décrire l’accès aux soins chirurgicaux chez les patients sans domicile fixe dans un hôpital de soins tertiaires au Canada.
Nous avons passé en revue les dossiers médicaux de patients adultes (âge > 18 ans) sans domicile fixe ayant consulté aux urgences de l’Hôpital d’Ottawa entre le 1^er janvier 2013 et le 31 décembre 2014, et pour qui une consultation en chirurgie avait été demandée. Nous avons analysé les données au moyen de statistiques descriptives.
Une consultation en chirurgie a été demandée lors de 129 visites aux urgences, pour 97 patients (77 hommes [79 %], âge moyen 46,7 ans). La plupart de ces patients vivaient dans des refuges (77 [79 %]) et bénéficiaient d’un régime d’assurance maladie provincial (82 [84 %]), mais seulement 35 (36 %) avaient un médecin de famille. Le nombre moyen de visites, toutes raisons confondues, a été de 7,9 (écart-type 13,7) (entre 1 et 106). La majorité des demandes de consultations en chirurgie (83 [64,3 %]) concernaient des lésions traumatiques et le service le plus souvent appelé en consultation (52 [40,3 %]) était la chirurgie orthopédique. Un peu moins de la moitié (48 [49 %]) des patients envoyés en consultation se sont présentés à au moins un rendez-vous en clinique externe, et seulement le tiers d’entre eux (33 [34 %]) se sont soumis au suivi complet.
Les patients sans domicile fixe qui consultent aux urgences et ont besoin de soins chirurgicaux étaient principalement des hommes hébergés dans des refuges ayant le plus souvent consulté pour des blessures traumatiques. Les services ambulatoires actuels ne répondent peut-être pas aux besoins chirurgicaux de ces patients, car plusieurs n’y accèdent pas. Il faudrait envisager d’autres approches, particulièrement en ce qui concerne les services très en demande, comme l’orthopédie, pour faciliter l’accès aux soins chez cette population.

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Original ContributionCharacteristics of Medicaid enrollees with frequent ED use

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study setting

Definition of frequent users

Sample characteristics

Discussion

Conclusion

Ann Emerg Med

J Emerg Med

Am J Emerg Med

Ann Emerg Med

Frequent users of Massachusetts emergency departments: a statewide analysis

Ann Emerg Med

Predictors and outcomes of frequent emergency department users

Acad Emerg Med

Epidemiologic analysis of an urban, public emergency department's frequent users

Acad Emerg Med

Frequent users of emergency department services: gaps in knowledge and a proposed research agenda

Acad Emerg Med

Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter?

Med Care

Original Contribution
Characteristics of Medicaid enrollees with frequent ED use