Factors on Emergency Department Hospitalization Practices Keith - PowerPoint PPT Presentation

The Impact of Patient Non-Clinical Factors on Emergency Department Hospitalization Practices Keith Kocher , Ryan McCammon, Kenneth Langa Department of Emergency Medicine Institute for Healthcare Policy and Innovation @kekocher University of Michigan ARM | 6.24.18 kkocher@umich.edu

Disclosures • Agency for Healthcare Research and Quality (AHRQ) – Career development award – K08 HS024160 – “Understanding the Causes and Consequences of Variation in Emergency Department Hospitalization Practices Across the United States” @kekocher

Background and Objectives Non Clinical Factors Clinical Factors • Social • Demographics • Illness supports • Financial • Severity • Comorbidities supports • Functional status ED hospitalization decisions may require balancing acute medical care needs with patient social support and functional capacity @kekocher

Population Studied Assess impact of non-clinical factors on ED hospitalization practices Health and Retirement Study linked to Excluded ED visits ending Medicare claims, 1999-2012 in ICU or transfers (median lag = 370 days; IQR = 183-569 days) (less discretionary) 52,733 ED visits from z 11,179 unique individuals (43.7% hospitalized) By condition (using clinical classification software, CCS, categories) @kekocher

Study Design Constructed regression models Model 4 Model 3 Model 2 Model 1 • Functional • Socioeconomic • Clinical • Base status • Demographics support factors Estimated differences in explanatory power of model = % change in C-statistic @kekocher

Findings Table 1. Demographic and Clinical Factors Associated with Odds of Hospitalization from ED. Demographic and Clinical Factors Adjusted Odds Ratio 95% CI Year of ED Visit [1998-2000, reference] (0.95 – 1.07) 2001-2003 1.01 (0.89 – 1.00) 2004-2006 0.94 (0.88 – 0.99) 2007-2009 0.94 (0.81 – 0.92) 2010-2012 0.86 Gender [male, reference] (0.79 – 0.85) Female 0.82 Age [65-74, reference] (1.09 – 1.19) 75-84 1.14 (1.24 – 1.38) 85+ 1.31 Race/ethnicity [non-Hispanic white, reference] (0.83 – 0.92) Non-Hispanic black 0.87 (0.75 – 0.87) Hispanic/other 0.81 Count Chronic Condition Warehouse (CCWs) [0-3, reference] (1.51 – 1.68) 4-5 1.59 (2.14 – 2.37) 6-8 2.25 (2.88 – 3.24) 9+ 3.06 Self-Reported Health [excellent/very good, reference] (1.02 – 1.12) Good/fair/poor 1.07 @kekocher

Findings Table 2. Socioeconomic Factors Associated with Odds of Hospitalization from ED. Socioeconomic Status Adjusted Odds Ratio 95% CI Marital Status [Married/partnered, reference] (0.98 – 1.14) Separated/divorced/never married 1.06 (1.05 – 1.18) Widowed 1.11 Number of Household Residents [1, reference] (0.97 – 1.09) 2 1.03 (1.01 – 1.14) 3+ 1.07 Any Living Children [no, reference] (0.85 – 0.97) Yes 0.91 Any Living Siblings [no, reference] (0.89 – 0.97) Yes 0.93 Any Nearby Friends [no, reference] (0.91 – 0.98) Yes 0.94 Years of Schooling [12, reference] (0.88 – 0.97) 0-11 0.92 (0.89 – 1.00) 13-15 0.94 (0.89 – 1.00) 16+ 0.94 Household Assets [Lowest quartile, reference] (1.02 – 1.13) Second lowest quartile 1.07 (0.97 – 1.09) Third lowest quartile 1.03 (0.97 – 1.10) Highest quartile 1.03 Urban Residence [No, reference] (1.31 – 1.43) Yes 1.37

Findings Table 3. Functional Status Factors Associated with Odds of Hospitalization from ED. Functional Status Adjusted Odds Ratio 95% CI Activities of Daily Living Difficulties [none, reference] (0.92 – 1.02) 1-2 0.97 (0.96 – 1.09) 3+ 1.03 Mobility Difficulties [none, reference] (1.07 – 1.19) 1-2 1.13 (1.27 – 1.45) 3+ 1.36 Agility Difficulties [none, reference] (0.95 – 1.06) 1-2 1.01 (0.92 – 1.05) 3+ 0.98 Cognition [normal, reference] (0.97 – 1.06) Cognitive impairment, no dementia (CIND) 1.02 (1.01 – 1.13) Dementia 1.07 6 questions related to performing daily activities: 4 questions related to large muscle strength: (1) sit for two hours, (2) get up from a chair after sitting for long (1) walk several blocks, (2) walk one block, (3) climb one flight of stairs without resting, (4) climb several periods (3) lift or carry weights of more than 10 lbs, (4) stoop, kneel, or crouch, (5) pull or push a large object, (6) reach or extend flights of stairs without resting their arms above the shoulder level @kekocher

Findings Table 4. Stepwise Difference in Explanatory Power of the Model for Propensity of Hospitalization from the Emergency Department by Clinical Condition. Model % Change (C-Statistic) C-Statistic Clinical Condition 2 . Model 1 + 3 . Model 2 + 4 . Model 3 + 1 . Base + Model 2 to Clinical Socioeconomic Functional Demographics 4 Factors Support Status Fracture of neck of femur (hip) 0.642 0.683 0.877 0.909 33.1% Allergic reactions 0.694 0.737 0.891 0.955 29.6% Other upper respiratory disease 0.614 0.675 0.794 0.815 20.7% Delirium, dementia, amnestic & cognitive disorders 0.617 0.623 0.719 0.736 18.1% Coronary atherosclerosis & other heart disease 0.583 0.597 0.687 0.704 17.9% Open wounds of extremities 0.657 0.681 0.769 0.791 16.2% Nausea and vomiting 0.620 0.651 0.735 0.754 15.8% Sprains and strains 0.637 0.668 0.719 0.765 14.5% Malaise and fatigue 0.636 0.680 0.742 0.777 14.3% Other upper respiratory infections 0.600 0.753 0.837 0.858 13.9% Open wounds of head; neck; and trunk 0.740 0.743 0.787 0.845 13.7% Intestinal obstruction without hernia 0.608 0.629 0.690 0.711 13.0% Headache; including migraine 0.649 0.694 0.767 0.779 12.2% @kekocher

Findings Table 4. Stepwise Difference in Explanatory Power of the Model for Propensity of Hospitalization from the Emergency Department by Clinical Condition. Model % Change (C-Statistic) C-Statistic Clinical Condition 2 . Model 1 + 3 . Model 2 + 4 . Model 3 + 1 . Base + Model 2 to Clinical Socioeconomic Functional Demographics 4 Factors Support Status Urinary tract infections 0.621 0.671 0.683 0.708 5.5% Asthma 0.618 0.722 0.747 0.761 5.4% Diverticulosis and diverticulitis 0.731 0.752 0.777 0.792 5.3% Gastrointestinal hemorrhage 0.599 0.656 0.690 0.690 5.2% Syncope 0.577 0.621 0.638 0.653 5.2% Residual codes; unclassified 0.668 0.680 0.700 0.715 5.1% Other lower respiratory disease 0.643 0.665 0.686 0.697 4.8% Fluid and electrolyte disorders 0.597 0.631 0.651 0.660 4.6% Skin and subcutaneous tissue infections 0.604 0.700 0.722 0.731 4.4% Other fractures 0.608 0.685 0.697 0.709 3.5% Cardiac dysrhythmias 0.585 0.638 0.653 0.659 3.3% Conditions associated with dizziness or vertigo 0.614 0.621 0.637 0.641 3.2% Superficial injury; contusion 0.613 0.690 0.695 0.711 3.0% @kekocher

Limitations Medicare Lag Time Administrative Claims Diagnoses @kekocher

Conclusions and Implications Discharge Admission For some conditions, changing ED hospitalization practices likely requires accounting for a patient’s ability to function independently on discharge @kekocher