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The American Journal of Managed Care February 2015
A Multidisciplinary Intervention for Reducing Readmissions Among Older Adults in a Patient-Centered Medical Home
Paul M. Stranges, PharmD; Vincent D. Marshall, MS; Paul C. Walker, PharmD; Karen E. Hall, MD, PhD; Diane K. Griffith, LMSW, ACSW; and Tami Remington, PharmD
Quality’s Quarter-Century
Margaret E. O'Kane, MHA, President, National Committee for Quality Assurance
How Pooling Fragmented Healthcare Encounter Data Affects Hospital Profiling
Amresh D. Hanchate, PhD; Arlene S. Ash, PhD; Ann Borzecki, MD, MPH; Hassen Abdulkerim, MS; Kelly L. Stolzmann, MS; Amy K. Rosen, PhD; Aaron S. Fink, MD; Mary Jo V. Pugh, PhD; Priti Shokeen, MS; and Michael Shwartz, PhD
Did Medicare Part D Reduce Disparities?
Julie Zissimopoulos, PhD; Geoffrey F. Joyce, PhD; Lauren M. Scarpati, MA; and Dana P. Goldman, PhD
Health Literacy and Cardiovascular Disease Risk Factors Among the Elderly: A Study From a Patient-Centered Medical Home
Anil Aranha, PhD; Pragnesh Patel, MD; Sidakpal Panaich, MD; and Lavoisier Cardozo, MD
Employers Should Disband Employee Weight Control Programs
Alfred Lewis, JD; Vikram Khanna, MHS; and Shana Montrose, MPH
Race/Ethnicity, Personal Health Record Access, and Quality of Care
Terhilda Garrido, MPH; Michael Kanter, MD; Di Meng, PhD; Marianne Turley, PhD; Jian Wang, MS; Valerie Sue, PhD; Luther Scott, MS
Leveraging Remote Behavioral Health Interventions to Improve Medical Outcomes and Reduce Costs
Reena L. Pande, MD, MSc; Michael Morris; Aimee Peters, LCSW; Claire M. Spettell, PhD; Richard Feifer, MD, MPH; William Gillis, PsyD
Decision Aids for Benign Prostatic Hyperplasia and Prostate Cancer
David Arterburn, MD, MPH; Robert Wellman, MS; Emily O. Westbrook, MHA; Tyler R. Ross, MA; David McCulloch, MD; Matt Handley, MD; Marc Lowe, MD; Chris Cable, MD; Steven B. Zeliadt, PhD; and Richard M. Hoffman, MD, MPH
Faster by a Power of 10: A PLAN for Accelerating National Adoption of Evidence-Based Practices
Natalie D. Erb, MPH; Maulik S. Joshi, DrPH; and Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI
Differences in Emergency Colorectal Surgery in Medicaid and Uninsured Patients by Hospital Safety Net Status
Cathy J. Bradley, PhD; Bassam Dahman, PhD; and Lindsay M. Sabik, PhD
The Role of Behavioral Health Services in Accountable Care Organizations
Roger G. Kathol, MD; Kavita Patel, MD, MS; Lee Sacks, MD; Susan Sargent, MBA; and Stephen P. Melek, FSA, MAAA
Patients Who Self-Monitor Blood Glucose and Their Unused Testing Results
Richard W. Grant, MD, MPH; Elbert S. Huang, MD, MPH; Deborah J. Wexler, MD, MSc; Neda Laiteerapong, MD, MS; E. Margaret Warton, MPH; Howard H. Moffet, MPH; and Andrew J. Karter, PhD
The Use of Claims Data Algorithms to Recruit Eligible Participants Into Clinical Trials
Leonardo Tamariz, MD, MPH; Ana Palacio, MD, MPH; Jennifer Denizard, RN; Yvonne Schulman, MD; and Gabriel Contreras, MD, MPH
A Systematic Review of Measurement Properties of Instruments Assessing Presenteeism
Maria B. Ospina, PhD; Liz Dennett, MLIS; Arianna Waye, PhD; Philip Jacobs, DPhil; and Angus H. Thompson, PhD
Currently Reading
Emergency Department Use: A Reflection of Poor Primary Care Access?
Daniel Weisz, MD, MPA; Michael K. Gusmano, PhD; Grace Wong, MBA, MPH; and John Trombley II, MPP

Emergency Department Use: A Reflection of Poor Primary Care Access?

Daniel Weisz, MD, MPA; Michael K. Gusmano, PhD; Grace Wong, MBA, MPH; and John Trombley II, MPP
An original emergency department patient survey, insurance claims data, and administrative records are used to examine the characteristics of nonurgent users.
To determine whether the use of the emergency department (ED) for nonurgent care reflects poor access to community-based primary care providers (PCPs).

Study Design
Using a survey of ED patients, insurance claims data, and administrative records identifying demographic factors, we analyzed the use of the ED in an impoverished area of Brooklyn, New York.

We examined original survey data to investigate the extent to which residents of northern and central Brooklyn use EDs for nonemergencies and whether these patients have access to PCPs. We used data from health insurers operating in northern and central Brooklyn, and New York state hospital ED visit data to investigate the factors influencing ED visits for ambulatory care–sensitive conditions (ACSCs). Logistic regression was used to identify characteristics that predict ED visits not resulting in admission for ACSCs.

Of 11,546 patients that completed our survey, the presenting complaint was self-described as emergent by 57%, 30% had no PCP, and 19% reported no health insurance coverage. Using health insurance plan encounter data, only 15 % of patients had seen any provider within 1 week of the ED visit. Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.

Correlating data from 3 sources, we suggest that the expansion of insurance under the Affordable Care Act may not be sufficient to reduce ED use for nonurgent conditions.

Am J Manag Care. 2015;21(2):e152-e160
We analyzed whether the nonurgent use of the emergency department (ED) in an impoverished area of Brooklyn, New York, is associated with poor access to primary care and other modifiable factors. We found:
  • Insurance type, age, gender, race/ethnicity, and socioeconomic status of area of residence influence the likelihood of these ED visits.
  • Medicaid clients, rather than the uninsured, account for the largest share of patients using EDs for nonurgent conditions.
  • Nonurgent ED visits are rarely preceded by a visit to a primary care provider, and this circumstance was unrelated to the type of health insurance.
The implementation of the Patient Protection and Affordable Care Act, with its expansion of public and private health insurance, raises questions about future use of the emergency department (ED), especially in deprived areas. There is evidence that, despite healthcare reform and the expansion of insurance coverage, there will be inadequate access to primary care for the newly insured. This, combined with a reduction in financial barriers to those using the ED, could increase demand for ED services.1-3

The ED is not an optimal site for nonurgent care. Nonemergent care delivered in the ED worsens overcrowding, reduces patient satisfaction, and is more costly than care offered in other settings.4 Treatment is often delivered without the availability of the complete medical history and without the capacity to ensure follow-up, resulting in episodic, fragmented, low-value care.

Annual ED visit rates in the United States have increased more than would be expected from population growth.5 An increasing number of uninsured and Medicaid patients contribute to rising ED visit rates.6,7 Factors known to influence an individual’s decision to visit the ED for nonurgent care have been reviewed.8 The recent healthcare reform debates and the pressure to redesign Medicaid to reduce state budget deficits have prompted implementation of measures designed to reduce ED use, despite evidence that diverting low-acuity cases away from the ED results in smaller savings than strategies to reduce inpatient admissions.9

The areas of northern and central Brooklyn are deprived sections of New York City with a large percentage of minorities, high unemployment, poverty and crime rates, and a significant percentage of households on public assistance and receiving food stamps. There are known poor health outcomes, including high rates of inpatient stays for ambulatory care–sensitive conditions (ACSCs) and premature mortality.10

In this paper we investigate the extent to which ED visits in northern and central Brooklyn occur for diagnoses that could have been treated in another setting, and we explore the reasons patients use EDs for the treatment of nonurgent conditions, including limitations in access to primary care. Preventable encounters with the healthcare system in the ED for ACSCs, a measure of limited access to quality primary care and poor care coordination,11-13 should be responsive to system changes that direct patients to non-ED care settings.

Because there is no single database that allows us to explore these questions, we combine data from 3 different sources to help us develop and test hypotheses. To assess the extent to which patients are treated in EDs for nonurgent conditions, we employ the rates of ED visits for ACSCs not resulting in admission. Administrative data, from the New York Statewide Planning and Research Cooperative System (SPARCS), document the extent of this potentially preventable ED use, and we analyze associated factors including insurance status and demographic and neighborhood factors. To complement the administrative data, we report findings from an original survey describing Brooklyn patients’ use of the ED. The survey allows us to explore whether patients believe their visit to the ED is an emergency and to identify other factors that may influence the use of EDs for nonurgent conditions. We use insurance data from plans operating in Brooklyn to investigate whether patients who have visited the ED for ACSCs have received outpatient care in the weeks before or after the ED visit. This information, with survey data, can help us understand whether patients who present in the ED for nonurgent conditions are receiving primary care.


The Brooklyn Health Care Improvement Project (BHIP) (see eAppendix [available at] for additional information),14 directed by researchers at the State University of New York–Downstate, includes a coalition of northern and central Brooklyn federally qualified health centers (FQHCs), hospitals, insurance plans, and community-based organizations. BHIP was funded by a 2009 New York State Health Care Efficiency and Affordability Law grant to develop a comprehensive health planning strategy for a designated area within northern and central Brooklyn covering more than 1 million lives. BHIP collected data to develop and evaluate strategies for reducing unnecessary ED visits.

We triangulated our analysis of ED healthcare-seeking behavior for primary care-treatable conditions (ie, ACSCs) by our study population. We examined original survey data from a large sample of ED patients to investigate the extent to which EDs are used for self-reported nonemergencies and whether these patients report having access to primary care providers. The survey, of a total of 11,546 patients or their representatives, was completed in 2 rounds (two 2-week spans, each week including its full 168 hours) and represents approximately one-third of individuals visiting the ED at any 1 of the 6 BHIP participating hospitals. The survey was completed during the last 2 weeks in January 2011 and the first two weeks of August 2011. (The survey instrument is available in the eAppendix.)

Encounter data from health insurers operating in northern and central Brooklyn is used to investigate the relation between ED visits and visits to other outpatient care sites by patients with Medicaid and commercial health coverage. We examined de-identified insurance claims data, institutional and professional files (which are the parts of the insurance claims data) from 2007 to 2009, from 8 insurers serving the study area. These data were pooled and classified as commercial (approximately 500,000 covered lives) or Medicaid (389,000 covered lives), and divided into children (aged <18 years of age and representing 47% of members with claims) and adults (aged 18 years and over) for analysis.

Finally, ED visits for ACSCs (Billings’ definition11) that do not result in admission to the hospital are analyzed using SPARCS hospital ED visit data. This population-based administrative data set is used to conduct a logistic regression analysis (SPSS version 19, IBM, Amonk, New York). The ED visit data for years 2007 through 2009 included randomly generated personal identifiers and residence geo-coded to 2010 US Census Tract (CT) boundaries, to link the data to 2010 US CT-level variables. The dependent variable is an ED visit for an ACSC diagnosis that did not result in an inpatient stay. Individual-level independent variables include age, gender, race/ethnicity, and primary payer. The model controls for CT community-level variables (derived from US Census 2010, file SF-1) include median household income, education achieved, self-assessed English language competence, and area housing vacancy rates. As a proxy for primary care provider (PCP) availability, the model includes the CT age-adjusted rate of inpatient discharges for ACSCs, a better indicator of PCP availability than the number of physicians in the neighborhood.15


Survey respondents were 57% female and 64% native-born, and 86% had lived in the same residence for more than 1 year (Table 1). Self-identified race and ethnicity reflect the population in the study area: 79% identified themselves as black, 3% as white, and 0.5% as Asian. Hispanics accounted for 20.5%. Of all respondents, 57% indicated that their visit was a medical emergency, 30% stated that they had no PCP, and 19% reported no health insurance coverage. Rates of coverage exceeded 90% in those younger than 18 years and older than 65 years, and averaged 76% for the 18- to 64-year-old age group. Medicare accounted for 10% of all payers, while 20% were covered by commercial insurance. Medicaid including Child Health Plus or Family Health Plus accounted for 51%.

Of those who stated that their visit was nonemergent, one-third used the ED for convenience or because it is their usual source of care; 29% could not schedule a PCP appointment, believed the wait for an appointment was too long, or were advised by their usual source of care to present to the ED. Lack of insurance or lower out-of-pocket cost accounted for 6% of visits. Of those survey respondents claiming to not have a PCP, 20% are covered by a Medicaid managed care plan.

Encounter data from the insurance plans reveal that most patients visiting an ED in northern and central Brooklyn for ACSCs do not make regular visits to community or institution based non-ED providers. Timing of visits made before and after an ED visit for ACSCs are presented in Table 2. Fifteen percent of the patients presenting to the ED with an ACSC had seen any covered provider within 1 week prior to their visit and 38% had seen a provider within 4 weeks. The percentage of patients seeing a provider prior to an ED visit for an ACSC varied little with type of coverage or age group. Follow-up visits with a non-ED provider after an ED visit for an ACSC diagnosis occurred in about 45% of patients for whom we have encounter data, despite the generic instructions to seek follow-up appointments with their PCP. These findings are consistent with self-reported information from the survey about access to primary care providers.

A summary of the characteristics of the patients residing in our study area visiting EDs as compared with the residents of all of Brooklyn is presented in Table 3. The odds of an ED visit for an ACSC diagnosis not resulting in admission is lower among younger people, women, and among those classified as Asian (Table 4). The odds of visits by Medicare beneficiaries and Medicaid clients are significantly higher than those for patients with commercial insurance. The odds of an uninsured patient visiting an ED for an ACSC are no different than the odds of a privately insured patient making such a visit. Residing in a census tract with the lowest quartile of household median income, with highest rates of those without at least a high school education, with the highest vacant housing rates, and with the highest rates of those who do not speak English well are all associated with statistically significant higher odds ratios of ED visits for ACSCs. There is almost no relationship between ED visits for ACSCs and access to local primary care as measured by area hospital discharge rates for ACSCs.


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