Abstract
Efforts are underway to understand recent increases in emergency department (ED) use and to offer case management to those patients identified as high utilizers. Homeless Veterans are thought to use EDs for non-emergent conditions. This study identifies the highest users of ED services in the Department of Veterans Affairs and provides descriptive analyses of these Veterans, the diagnoses for which they were seen in the ED, and differences based on their homeless status. Homeless Veterans were more likely than non-homeless Veterans to have >10 visits in the 2014 calendar year (12% vs. <1%). Homeless versus non-homeless Veterans with >10 visits were more often male, <age 60, and non-married. Non-homeless Veterans with >10 ED visits were often treated for chest and abdominal pain, and back problems, whereas homeless Veterans were frequently treated for mental health/substance use. Tailored case management approaches may be needed to better link homeless Veterans with high ED use to appropriate outpatient care.
Keywords: Homeless Veterans, Emergency Department, High Utilizers
Introduction
The use of emergency and urgent care services is rising in the US. The consequences of using the emergency department (ED) for non-emergent conditions translate to overcrowding of EDs, perceived lower quality of care, decrease in access to those who really need the ED, and an overall increase in costs to the health care system. High utilization of EDs has negative effects on patients and health care workers, resulting in frustration with the health care system in general. Efforts are underway to better understand the use of the ED for non-emergent conditions, and to offer patients identified as high utilizers of the ED (also called super-utilizers) customized case management in an attempt to decrease ED use and encourage ambulatory and primary care visits. To date, these high utilizer programs have had mixed success in diverting patients from using the ED as a usual source of care to more traditional primary and ambulatory care venues [1,2]. A key preliminary step is to characterize those patients who are the highest users of the ED in terms of their demographics, co-morbidities, and appropriateness of ED use. One group that might be well suited for high utilizer programs is homeless Veterans. Prior studies have documented high ED use among homeless patients, and homelessness is more common among Veterans than in civilian populations. Compared to their non-homeless counterparts, Veterans experiencing homelessness are thought to more frequently use EDs for non-emergent conditions. In order to tailor high utilizer programs for homeless Veterans, there is a need to better understand the prevalence of high ED use, characteristics of high utilizers, and common reasons for ED use among homeless and non-homeless Veterans. This study aimed to examine differences between homeless and non-homeless Veterans in the 1) frequency of ED use in one calendar year, and 2) sociodemographic characteristics and clinical diagnoses among those identified as the highest ED utilizers.
1. Methods
1.1. Administrative data related to ED and urgent care use in VA hospitals
The US Department of Veterans Affairs (VA) serves nearly 6 million unique Veterans through a network of 152 hospitals around the US. Many of these hospitals have emergency departments and urgent care clinics. Administrative data on ED and urgent care clinic use that were collected during routine clinic care from January 1 to December 31, 2014 were extracted from the VA corporate data warehouse using Veterans Informatics and Computing Infrastructure (VINCI), a secure research portal [3].
1.2. Data analysis
Descriptive statistics were used to analyze demographic and ED/urgent care visits for the 12-month study period. Primary International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are entered into the electronic medical record by providers at the time of care. All ICD-9-CM codes were assigned to a category using Clinical Classifications Software (CCS) that was developed for the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality [4]. Those Veterans who had administrative evidence of homelessness at the ED/urgent care visit were identified as previously described [5], using ICD-9-CM codes for lack of housing (V60.0) and for housing instability (V60.1 Inadequate housing, V60.89 Other specified housing or economic circumstances, and V60.9 Unspecified housing or economic circumstances). The number of ED/urgent care visits per Veteran were grouped and the highest users were defined as those having >10 visits in a 12-month period (11 and above). Details of visits of these highest utilizers were examined and stratified by their housing status (homeless or non-homeless) at the time of the ED/urgent care visit.
2. Results
2.1. Number of ED/Urgent care visits by Veterans in 2014
A total of 1,018,741 unique Veterans accounted for nearly 2 million ED/urgent care visits during the calendar year 2014. Veterans had a mean of 2 ED/urgent care visits (median 1, range 1–237). Homeless Veterans had higher numbers of visits as compared to non-homeless (Table 1). A greater percentage of homeless Veterans (948, 12.4%) had >10 ED/urgent care visits during the study period than non-homeless Veterans (<1%).
Table 1.
Emergency Department and Urgent Care Visits in VA Hospitals, January 1 to December 31, 2014.
| Total (N=1,018,741) | Non-Homeless (N=1,011,107) | Homeless or With Housing Instability (N=7,634) | |
|---|---|---|---|
| Average Number of ED/Urgent Care Visits (Median, Range) | 2 (1, 1 – 237) | 1 (1, 1 – 131) | 5 (4, 1 – 237) |
| ED/Urgent Care Visits | N (%) | N (%) | N (%) |
| 1 | 571,162 (56.1) | 569,657(56.3) | 1,505 (19.7) |
| 2 | 219,095 (21.5) | 217,842 (21.5) | 1,253 (16.4) |
| 3–10 | 220,947 (21.7) | 217,019 (21.5) | 3,928 (51.5) |
| 11 and higher | 7,537 (0.74) | 6,589 (0.65) | 948 (12.4) |
2.2. Sociodemographic characteristics of those with >10 ED/urgent care visits
Veterans with >10 ED/urgent care visits were predominantly male (92.2%). More than half of high utilizers were non-Hispanic White (56.3%), over age 60 (53.6%), and separated, divorced, or widowed (52.5%). Most (84.1%) never saw active combat during their military service. Compared to non-homeless Veterans, those with experiences of homelessness or housing instability were more frequently male (96.1% vs 91.6%), and younger (36.2% vs. 56.1% over age 60), but less frequently married (6.0% vs. 30.0%).
2.3. Frequent diagnoses of those with >10 ED/urgent care visits in a 12-month period
Of non-homeless Veterans with >10 ED/urgent care visits, 23% were treated for diseases related to the chest pain, 22% for abdominal pain, and 21% for back problems (Table 2). Of the homeless Veterans with >10 ED/urgent care visits, more than one-quarter were seen for alcohol dependence (31%), depressive disorder (29%), and alcohol abuse (28%).
Table 2.
Most Frequent Diagnoses of Veterans with >10 ED/Urgent Care Visits in VA Hospitals, January 1 to December 31, 2014.
| Non-Homeless (N=1,011,107) | Homeless or With Housing Instability (N=7,634) | ||||
|---|---|---|---|---|---|
|
| |||||
| ICD Code | Description | N (%) | ICD Code | Description | N (%) |
| 786.5 | Unspecified Chest Pain | 1,539 (23.4) | V60.0 | Lack of Housing | 413 (43.6) |
| 789 | Abdominal Pain | 1,459 (22.1) | 303.9 | Alcohol Dependence | 293 (30.9) |
| 724.2 | Lumbago | 1,389 (21.1) | 311 | Depressive Disorder | 273 (28.8) |
| 496 | Chronic Airway Obstruction | 1,041 (15.8) | 305 | Alcohol Abuse | 266 (28.1) |
| 599 | Urinary Tract Infection | 961 (14.6) | V62.84 | Suicidal Ideation | 263 (27.7) |
| 465.9 | Acute Upper Respiratory Infection | 807 (12.2) | 724.2 | Lumbago | 212 (22.4) |
| 682.9 | Cellulitis and Abscess | 755 (11.5) | 786.5 | Chest Pain | 207 (21.8) |
| 786.09 | Dyspnea/Respiratory Abnormality | 742 (11.3) | 303 | Alcohol Intoxication | 164 (17.3) |
| 784 | Headache | 730 (11.1) | 729.5 | Pain in Limb | 164 (17.3) |
| 786.59 | Other Chest Pain | 728 (11.1) | 789 | Abdominal Pain | 154 (16.2) |
3. Discussion
To our knowledge, this is the first study to characterize the highest utilizers of the ED in US Department of Veterans Affairs hospitals. One in nine homeless ED/urgent care patients were identified as high utilizers, many of whom received care for mental health/substance use issues that could potentially be addressed in outpatient settings. It will be important, once high users are identified to initiate regular case management to understand the reasons behind frequent ED use and to establish longitudinal primary care relationships. We acknowledge several limitations of this study. As only one calendar year of data were analyzed, no trends could be established. Future studies should include data from several years of ED and urgent care usage. There are inherent limitations to the reliability and completeness of administrative ICD coding of diagnoses of ED and urgent care visits. As we determined administrative evidence of homelessness only on the date of the ED/urgent care visit, it is possible that we underestimated the prevalence of homelessness among this group of Veterans. Correlating administrative evidence of homelessness in a time period prior to the ED/urgent care visit would be important to have a better estimate of the prevalence of homelessness among Veterans. Further detailed characterization of homeless Veterans who are the highest users of the ED is essential to understand their patterns of use and to inform tailored programs to mitigate inappropriate high utilization.
Acknowledgments
We appreciate our colleagues at VA Informatics and Computing Infrastructure (VINCI) for their assistance with accessing VA data. Funding from U.S. Dept of Veterans Affairs, Health Services Research & Development grant #IIR12-084. The views expressed are those of the authors and do not necessarily reflect the position or policy of the U.S. Dept of Veterans Affairs or the U.S. Government.
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