Unscheduled Care Access in the United States-A Tale of Two Emergency Departments

Abstract

Background:

Rural communities face challenges in accessing healthcare services due to physician shortages and limited unscheduled care capabilities in office settings. As a result, rural hospital-based Emergency Departments (ED) may disproportionately provide acute, unscheduled care needs. We sought to examine differences in ED utilization and the relative role of the ED in providing access to unscheduled care between rural and urban communities.

Methods:

Using a 20% sample of the 2012 Medicare Chronic Condition Warehouse, we studied the overall ED visit rate and the unscheduled care rate by geography using the Dartmouth Atlas’ hospital referral regions (HRR). We calculated HRR urbanicity as the proportion of beneficiaries residing in an urban zip code within each HRR. We report descriptive statistics and utilize K-means clustering based on the ED visit rates and unscheduled care rates.

Results:

We found rural ED use is more common and disproportionately the site of unscheduled care delivery when compared to urban communities. The ED visit and unscheduled care proportions were negatively correlated with increased urbanicity (r = −0.48, p < 0.001; r = −0.58, p < 0.001).

Conclusion:

he use and role of EDs by Medicare beneficiaries appears to be substantially different between urban and rural areas. This suggests that the ED may play a distinct role within the healthcare delivery system of rural communities that face disproportionate barriers to care access.

1. Introduction:

Rural communities face challenges in accessing hospital and physician healthcare services due to shortages of primary care and specialty physicians limiting office-based care capacity.[1–3] Numerous policies and programs have been developed to improve rural primary care access, yet rural hospital-based Emergency Departments (ED) often provide services for low-acuity visits.[4] This may reflect an outsized role for rural EDs in providing acute, unscheduled care needs as a result of limited ambulatory care capacity.

In urban areas, patients prefer the Emergency Department (ED) for unscheduled care either for convenience or for access to hospital-based services such as advanced imaging or parenteral therapy.[5–8] Patterns of rural ED use are relatively unexplored, despite the importance of healthcare access on rural patient outcomes.[9] To date, the use of the ED for unscheduled care based on geographic differences remains to be characterized. In this brief report, we accordingly sought to examine both differences in ED utilization as well as the relative role of the ED in the providing access to unscheduled care across geographic designations. We compared ED utilization for unscheduled care needs by urbanicity clusters, examining ED visit rates and ED unscheduled care proportions between geographies.

2. Methods:

2.1. Study setting and population

We used a 20% sample of the 2012 Medicare Chronic Condition Warehouse that includes all hospital and physician office claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. We have developed a framework for unscheduled care visits as all ED visits and physician office visits not limited to preventive care, screening services, immunizations or chronic care services. [10] Thus, unscheduled care visits are inclusive of ED visits but also include office-based visits for potentially unscheduled care needs.

We calculated outcomes and the inpatient hospitalization rate per 1000 beneficiaries at the hospital referral region (HRR) level using the Dartmouth Atlas (http://www.dartmouthatlas.org/). Geographic designation was determined by calculating HRR urbanicity as the proportion of beneficiaries residing in an urban zip code within each HRR (number of urban beneficiaries/total number of beneficiaries), yielding high 78%−100%, medium 46%−77%, and low 0%−45% levels of urbanicity through k-means clustering. All analyses were performed using SAS 9.4 (Cary, NC) and R version 3.4.3.

2.2. Outcomes

The primary outcomes were 1) ED visit rate per 1000 Medicare beneficiaries and 2) the ED unscheduled care proportion, defined as the proportion of all unscheduled care visits occurring in the ED setting. We calculated these outcomes as well as the inpatient hospitalization rate per 1000 beneficiaries at the hospital referral region (HRR) level using the Dartmouth Atlas. Outcomes were evaluated by geography based on the three urbanicity categories described above.

2.3. Statistical Analysis

We report descriptive statistics and utilize K-means clustering based on the ED visit rate and ED unscheduled care proportion to describe results. All analyses were performed using SAS 9.4 (Cary, NC) and R version 3.5.3.

2.4. Limitations

This study has a cross-sectional design, as a result we cannot infer reasons for ED visitation, but rather describe ED use patterns in the Medicare population. Further, our definition of unscheduled care may underestimate ED utilization for unscheduled care which may result in conservative estimates of the role of the ED in care delivery.[11] While our analysis was conducted in 2012 data, it is unlikely that these patterns are significantly changed in recent years given the stable insurance status and characteristics of the Medicare fee-for-service population.

3. Study Results:

Of 10,717,786 included Medicare beneficiaries, 22% visited the ED. The overall ED visit rate and hospitalization rates were 484 and 211 per 1000 beneficiaries. Of 33,570,113 unscheduled care visits, 5,192,235 (15.4%) occurred in the ED. We found wide variation in the overall HRR ED visit rate (Mean: 527 IQR: 447–609) and the HRR emergency unscheduled care proportion (Mean: 16% IQR: 13%−18%) and between urbanicity clusters. ED visit rates were positively correlated with ED unscheduled care (r = 0.41, p < 0.001) and hospitalization rates (r=.81, p < 0.001), while ED unscheduled care proportions were not correlated with the hospitalization rates (r=.07, p = 0.256).

Overall ED visit and unscheduled care proportions were negatively correlated with urban proportions (r = −0.48, p < 0.001; r = −0.58, p < 0.001) with rural areas experiencing higher ED visit rates and a greater proportion of emergency unscheduled care visits (Figure 1). Among three natural urbanicity clusters we found higher ED visit rates and unscheduled care proportions among rural HRRs corresponding with states with large rural populations, particularly in the northern and midwestern US (Figure 2). The correlation between ED visit rates and ED unscheduled care was significantly higher in urban HRRs (r=0.34) than in rural HRRs (r=0.15).

Figure 1.

ED Visit Rate and ED Unscheduled Care Proportion by HRR and Urbanicity Cluster ED visits per 1000 beneficiaries in relation to the ED unscheduled care proportion by urbanicity. Each urbanicity category of high, medium, and low was determined by calculating HRR urbanicity through k-means clustering.

Figure 2.

Geographic distribution of ED unscheduled care visit proportion by healthcare referral region (HRR). Geographic distribution is defined by the Dartmouth Atlas’ health care referral regions (HRR) superimposed on a map of the United States. The ED unscheduled visit proportion is reported reflecting the percent of unscheduled visits out of all ED visits for each HRR.

4. Discussion

In this national analysis of Medicare beneficiaries, we found substantial differences in the use and role of the ED for unscheduled care between urban and rural geographies. Use of the ED was not only more common in rural communities, but also disproportionately the site of unscheduled care delivery. Interestingly, we found no relationship between the proportion of unscheduled care delivered in the ED and hospitalization rates across all geographies. This may suggest that unscheduled ED visits do not drive hospital admissions and admission-related healthcare costs. Further, we found weaker correlations between overall ED visits and hospitalization rates in rural communities in comparison to their urban counterparts. This may be further evidence of the outsized role rural ED’s play in addressing unscheduled care and routine care needs and may reflect more limited outpatient capacity and access. While these ED visits may be served in non-hospital settings (e.g., urgent care), these are uncommon in the rural setting, which may be reflected in our findings of rural EDs as disproportionately the site of unscheduled care delivery.

These findings suggest that rural EDs may play a distinct role within the healthcare delivery system of their communities which face disproportionate barriers to access preventive, primary, specialty and hospital care. While there are no previous studies evaluating acute, unscheduled care needs by geography, some data exist to suggest that rural EDs are more likely to care for non-emergency conditions in low-income patients who are geographically distant from primary care.[4] With rising rural ED visits[12] and troubling declines in rural American health,[13] our findings indicate the need for innovative rural care delivery models that integrate EDs and emergency services into local systems of care to support the primary care framework - such as improved coordination of care, deployment of community paramedicine, and co-location of primary care. An increasing body of literature indicates that decision to use the ED for acute, unscheduled care needs[14] is not driven by a patient’s inability to navigate the health system, but rather a result of patient preference and inaccessible timely ambulatory care.[5, 6] The notion that the conventional, singular view of ED visitation as only necessary for acute time-sensitive illnesses is far from reality – particularly in the rural setting.

Delivery models that integrate EDs and emergency care into local systems of care may improve access and outcomes. One example is co-location of emergency physicians and primary care physicians in rural hospitals which concurrently utilize the ED setting as a hub for healthcare.[15] Another is deployment of community paramedicine to reduce ED visits and support chronic disease management.[16] Finally, coordination of care in the rural setting can be achieved post-hospitalization to reduce ED utilization.[17] Our findings may also inform ongoing state innovation on rural health care delivery, such as those funded by the Centers for Medicare and Medicaid Innovation (CMMI) in Pennsylvania and Vermont, which seek to transform rural healthcare delivery through use of global budgets.[15]

Our data indicate that states with large rural populations may consider deliberately using EDs as centers of care coordination with linkage to primary care. While this may require a physical restructuring of how care is delivered and investment in care coordination efforts, it would increase patient contact with primary care. Such approaches may drive increases in ED utilization which is more costly than non-hospital-based, episodic, unscheduled care; but our data indicate it is unlikely to drive increased hospitalizations and -associated, more costly, expenses. Rather, these approaches may improve care coordination while simultaneously reducing total acute care expenditures—a trend that should be closely observed and potentially supported by policymakers.

Glossary

ED

Emergency Department

HRR

Hospital Referral Region

IQR

Interquartile Range