2012 Update on U.S. emergency care and longitudinal trends (1995-2010)

Jesse M. Pines, MD, MBA, MSCE and Mark Zocchi, MPH

AHRQ National Meeting September 10, 2012

Disclosures Funding and support

Centers for Medicare and Medicaid Services National Quality Forum Agency for Healthcare Research and Quality Robert Wood Johnson Foundation Saudi Arabian Cultural Mission University of Cincinnati

Project co-authors / collaborators Ryan Mutter, PhD, AHRQ Lan Zhao, PhD, Social and Scientific Systems

Objectives Provide a update on emergency care for 2012

Where are we since the IOM report?

Describe emergency care policy issues and longitudinal trends in emergency care in the U.S.

Introduction Why does emergency care matter?

Asplin Ann Emerg Med 2003

Institute of Medicine Future of Emergency Care Series

(2006) Hospital-Based Emergency Care: At the

Breaking Point ED crowding, ambulance diversion, ED boarding

very common Call to end boarding, except under “extreme”

circumstances Emergency departments not prepared for mass-

casualty events Call for greater health information technology,

information-sharing

Emergency Medical Services: At the Crossroads

Emergency Care for Children: Growing Pains

Where are we in 2012? ED crowding, diversion, ED boarding very

common

Pitts Pines Ann Emerg Med 2012

Where are we in 2012? ED crowding, diversion, ED boarding very

common

Pitts Pines Ann Emerg Med 2012

What is causing crowding? Visits are going up

The total time spent in the ED is rising faster

What is causing crowding?

Pitts Pines Ann Emerg Med 2012

What is causing crowding?

Pitts Pines Ann Emerg Med 2012

Expanded literature on ED crowding ED crowding is associated with:

Poorer quality pain care Delays in medications Delays in critical tests Higher medication errors Higher rates of complications Lower quality care in pediatric asthma

ED boarding is associated with: Higher medical errors Higher mortality rates

Where are we in 2012? What has happened from a policy

perspective?

2008 ED National Quality Forum ED crowding measures ED LOS discharged, admitted, overall Left without being seen rate

2009 Diversion ban in Massachusetts

2011 – ED LOS measures released on Hospital Compare

Where are we in 2012? What may happen in the future?

2012 – ASPR-funded ED crowding/preparedness measurement concepts

2012 & beyond – ED LOS measures part of Value-Based Purchasing?

Where are we in 2012? 2012 – Joint Commission Flow Standard (82% of hospitals)

EP1: Hospital has a process that supports the flow of patients throughout the hospital.

EP2: Hospital must plan and care for the patients who are admitted and whose bed is not ready or a bed is unavailable.

EP3: Hospital must plan for the care for patients who are placed in an overflow location. (Appropriate care regardless of location)

EP4: Hospital should have a policy and procedure on diversion.

Where are we in 2012? EP5: Hospitals must measure and set goals for the components of

the patient flow process.

EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.

EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.

EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.

EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

Where are we in 2012? EP5: Hospitals must measure and set goals for the components of

the patient flow process.

EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.

EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.

EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.

EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

Next policy questions Why do people come to the ED?

Beyond the critically ill What are alternatives? How will new policy changes impact these trends?

What care are people receiving? Higher intensity care

Advanced radiography, laboratory tests, IVs Sicker patients Admissions

How is the ED changing over time, compared to other parts of the system At what cost?

Why do so many people come to the ED?

Ragin Acad Emerg Med 2005

How does the ED compare to alternatives?

Morgan Pines Am J Manag Care 2012

Policy changes and the ED Payment bundling, accountable care

organizations Will this impact the ED

How? Depends…..

Medical home model Early results that becoming a medical home is

associated with lower ED visits

Diversion of low-acuity patients to alternative settings Wellpoint; others

Has been somewhat effective, but may not reduce overall costs

Why do people come to the ED?

2009 NHAMCS data, CDC

Why do people come to the ED The reasons people

come to the ED (and get admitted to the hospital are not changing)

There are just more and more people, and the growth is outpacing population expansion

How is the intensity of care changing? More intense care, higher complexity care

SEDD 2004-2010: GA, HI, MA, MD, MO, NE, VT, WI

Emergency Department Visits: Percentage of Services (denominator = all ED records)

CPT Code 2004 2005 2006 2007 2008 2009 2010

99281 16% 15% 10% 16% 16% 16% 16%

99282 15% 14% 10% 14% 16% 15% 14%

99283 19% 19% 14% 24% 32% 34% 34%

99284 8% 9% 7% 14% 19% 21% 22%

99285 2% 3% 2% 5% 6% 7% 8%

How about hospital admissions?

2002 2003 2004 2005 2006 2007 2008 2009 20100.0

0.5

1.0

1.5

2.0

2.5

APR-DRG Severity by ED Status

ED Admission Non-ED Admission

Sev

erit

y

HCUP data, AHRQ

How about admission rates? Is the likelihood of admission increasing?

ED admission rates over time

2002 2003 2004 2005 2006 2007 2008 20090%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Per

cen

t A

dm

itte

d f

rom

ED

HCUP data, AHRQ

How about specific populations? ED admission rates are increasing for older

adults CDC data 36.2% in 2001; 38.7% in 2009

Numbers of ICU admissions are increasing dramatically CDC data 2.76 million in 2002-2003 4.14 million in 2008-2009

Pines J Am Geriatric Soc 2012 (in press) ; Mullins Pines Crit Care Med (under review)

Policy questions ED visits increasing Patients are sicker, more ICU-bounds Staying for more prolonged work-ups Admission rates are unchanged on average

Perhaps preventing some hospital admissions in younger patients?

Next questions: Where are ED visits increasing more? What is happening to the supply of EDs?

Total U.S. ED volume v. # of EDs

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

140,000,000

0

1,000

2,000

3,000

4,000

5,000

ED

Vo

lum

e (m

illi

on

s)

Dis

cret

e E

Ds

(th

ou

san

ds)

HCUP data, AHRQ

Profit v. non-profit v. public

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

60,000,000

70,000,000

80,000,000

90,000,000

100,000,000

0

1,000

2,000

3,000

For Profit Non profit

ED

Vo

lum

e (m

illi

on

s)

Dis

cret

e E

Ds

(th

ou

san

ds)

HCUP data, AHRQ

Urban v. rural location

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

20,000,000

40,000,000

60,000,000

80,000,000

100,000,000

120,000,000

0

1,000

2,000

3,000

Rural

ED

Vo

lum

e (m

illi

on

s)

Dis

cret

e E

Ds

(th

ou

san

ds)

HCUP data, AHRQ

Hospital average ED volume v. # EDs

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5000

10000

15000

20000

25000

30000

0

1,000

2,000

3,000

4,000

5,000

Ho

spit

al A

vera

ge

ED

Vo

lum

e (t

ho

usa

nd

s)

Dis

cret

e E

Ds

(th

ou

san

ds)

HCUP data, AHRQ

Growing role of ED admissions

Schuur Venkatesh New Engl J Med 2012

Average cost per admission

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2000

4000

6000

8000

10000

12000

ED Admissions Non-ED Admissions

Ave

rag

e C

ost

of

Ad

mis

sio

ns

(in

th

ou

san

ds

2010

Do

llar

s)

Pre-2000 costs are based on 2000 ratios.

HCUP data, AHRQ

ED admissions as a cost driver

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

50,000,000,000

100,000,000,000

150,000,000,000

200,000,000,000

250,000,000,000

ED Admissions Non-ED Admissions

To

tal

Co

st o

f A

dm

issi

on

s (i

n b

illi

on

s, 2

010

Do

llar

s)

Pre-2000 costs are based on 2000 ratios. Total pre-2000 costs may be underestimated due to missing data.

HCUP data, AHRQ

Recap ED crowding and boarding

How far have we come since the 2006 IOM Report

Trends in demand for emergency care in the U.S. Will this go unabated? What does this mean for U.S. healthcare costs?

Questions?