houston hospitals emergency department use study · numbered 780,076. of this number, 709,496 non...
TRANSCRIPT
HOUSTON HOSPITALS
EMERGENCY DEPARTMENT USE STUDY
January 1, 2006 through December 31, 2006
FINAL REPORT
Prepared By
School of Public Health University of Texas Health Science Center at Houston
Charles Begley, Patrick Courtney, Keith Burau
April 2008
2
TABLE OF CONTENTS
I. Executive Summary ........................................................................................3
II. Purpose ...........................................................................................................13
III. Methods ..........................................................................................................14
IV. Results ............................................................................................................18
ED Visits by Type……………………………..…………………………….18
Summary Tables and Figures
ED Visits by Month, Day of Week, and Time of Day……………………..21
Summary Tables and Figures
Primary Care-Related ED Visits by Patient Characteristics……….…….25
Summary Tables and Figures
Health Conditions of Patients with Primary and
Non-Primary Care-Related Visits………..…………………………….34
Summary Tables and Figures
Geographic Distribution of Patients with
Primary Care-Related Visits………….…..…………....……………....37
Summary Maps
V. 2002-2006 Comparison………………………………….…………………..48 Summary Tables and Figures
3
I. EXECUTIVE SUMMARY
The University Of Texas School Of Public Health has been collecting and analyzing
emergency department visit data in Harris County hospitals to monitor primary care-related use
of the emergency department. This report provides an analysis of 2006 ED visit data and
describes trends over the last five years.
Data and Analysis
Twenty five hospitals which have emergency departments (EDs) and provide a
substantial amount of discounted and free care to the uninsured of Harris County have provided
ED visit data for the year 2006. They include: two hospitals of the Harris County Hospital
District (Ben Taub General and Lyndon B. Johnson General); nine hospitals of the Memorial
Hermann Health Care System (Hermann/Texas Medical Center, Southwest, Southeast,
Northeast, Northwest, The Woodlands, Memorial City, Katy, and Sugar Land); four hospitals of
the Hospital Corporation of America, or HCA (Bayshore Medical Center, Spring Branch
Medical Center, East Houston Regional Medical Center, and West Houston Medical Center); St.
Joseph Medical Center; River Oaks Hospital (recently known as Twelve Oaks Medical Center);
Texas Children’s Hospital; two hospitals of CHRISTUS Gulf Coast (St. Catherine and St. John);
two hospitals of St. Luke’s (Episcopal Hospital and Community Medical Center); and three
hospitals of the Methodist Hospital System (Methodist/Texas Medical Center, San Jacinto
Methodist, and Methodist Willowbrook).
4
Each hospital supplied the following data elements on all ED visits that were made
during the period January 1, 2006 through December 31, 2006:
1. Date and time of admission to ED 2. Primary and secondary discharge diagnosis 3. Discharge date and time 4. Payment source 5. Patient age 6. Patient gender 7. Patient race/ethnicity 8. Patient ZIP code 9. Where discharged to (e.g. home, nursing home, etc.)
Visits that did not result in an admission were analyzed. The probability that each
nonadmitted visit was one or more of the following types of visits was assigned based on
applying the New York University ED Algorithm to the discharge diagnosis.
1. Non-emergent: Immediate treatment was not required within 12 hours. 2. Emergent-Primary Care Treatable: Treatment was required within 12 hours, but
could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting.
3. Emergent-ED Care Needed-Preventable/Avoidable: ED care was required within
12 hours, but the emergent nature of the condition was potentially preventable/ avoidable if timely/continuous primary care had been received for the underlying illness.
4. Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required
within 12 hours and primary care could not have prevented the condition.
The frequencies of visits for each diagnosis were multiplied by their respective
probabilities of visit type and then the number of visit types was aggregated for all diagnoses to
produce estimates of the total number of ED visits by type. ED visits in the first three categories
are considered primary care-related use of the ED. Those in the fourth category reflect non-
primary care-related use of the ED. The time and geographic pattern of primary care and non-
primary care-related ED visits are summarized in the report. In addition, the demographic,
5
coverage, and health conditions of patients with primary care and non-primary care-related visits
are shown. The Executive Summary and main body of the report present 2006 information for
twenty five hospitals. The comparison of data for the years 2002 through 2006 is for eleven
hospitals for which five years of data are available.
2006 Results
1. Total ED Visits (non hospitalized) by Type
♦ During 2006, 991,861 total ED visits were made to these 25 hospitals by residents of
the eight county area. Non hospitalized ED visits by residents of the eight county area
numbered 780,076. Of this number, 709,496 non hospitalized ED visits were made by
Harris County area residents (Table 1). This report represents 71.53% of all ED visits
and 90.95% of non hospitalized ED visits to these hospitals.
♦ 51.6% of all ED visits by Harris County residents in 2006 were primary care-related.
This represents 81.6% of categorized ED visits (Table 1). In 2005, 53.6% of all ED
visits were primary care related, and 82.6% of categorized ED visits were primary
care related. The 2006 report thus represents a decline in primary care related ED
visits.
♦ One fifth of all ED visits (20.7%) were non-emergent (Table 1). A slightly higher
percentage (22.7%) were primary care treatable. This represents 32.8% and 36.2%
respectively, of categorizable visits (Table 1).
♦ 166,872 ED visits (23.5% of total ED visits) were injuries, and 10,466 ED visits
(2.2% of total) were either mental health, alcohol, or drug related (Table 1).
6
2. ED Visits by Month, Day, and Time
• ED visits by Harris County residents declined during the year, peaking in January at
roughly 42,000, with August having the fewest visits. The summer months overall
had the fewest ED visits (Figure 2). Primary care-related ED visits followed roughly
the same pattern.
• There was almost no variation in the number of total ED visits by day of the week.
The exception was a peak on Wednesday (Figure 3).
• The smallest number of ED visits were between the hours of 4 AM and 6 AM, the
most were between the hours of 11 AM and 8 PM (this pattern is unchanged from
2005). Primary care-related ED visits followed a similar pattern (Figure 4). It should
be noted that a large volume of primary care-related ED visits occurred during hours
in which physicians’ offices and outpatient clinics would normally be open.
3. Primary Care-Related ED Visits by Patient Characteristics
• 32.4% of primary care-related visits were by patients who were uninsured (32.9% in
2005), 25.8% had Medicaid (30.8% in 2005), 30.1% had private insurance (24.8% in
2005), and 9.2% had Medicare (8.6% in 2005) (Figure 5).
• 34.4% of primary care-related visits were by Blacks, 32.5% Hispanics, 25.7%
Whites, 2.3 Other, and 1.3% Asian (Figure 6).
• 54.3% of primary care-related visits were by adults age 18-64, 38.1% were children
and youth age 0-17, and 7.6% were adults aged 65 or older (Figure 7).
• 57.6% of primary care-related visits were by females and 42.4% were by males
(Figure 8).
7
• Patients with Medicaid had the highest proportion of ED visits that were primary
care-related (77.3%), with patients on Medicare having the lowest proportion at
74.3%. 84.5% of ED visits by the uninsured were primary care-related, an increase
from 2005 (Figure 9).
• Race/ethnicity groups with the highest proportion of visits primary care-related were
Blacks (83.9%) and Hispanics 82.6% (Figure 10).
• The proportion of visits that were primary care-related declined with age: 88.1% for
children age 17 and younger, 78.9% for adults age 18 to 64, and 72.7% for adults age
65 and over (Figure 11). The same decline by age was also seen in 2005.
• There was almost no variation by gender for proportion of visits that were primary
care-related. However, a higher proportion of women than men had visits that were
considered non emergent (Figure 12).
4. Health Conditions of Patients with Primary and Non-Primary Care-Related Visits
• The five most frequent diagnoses of patients with primary care-related visits were:
acute upper respiratory infection not otherwise specified, otitis media not otherwise
specified, fever, noninfectious gastroenteritis, and urinary tract infection not
otherwise specified (Table 4). A comparison with the ED report using the 2005 data
shows the same top results, although in a slightly different order.
• The five most frequent diagnoses of patients with non-primary care related ED visits
were chest pain not otherwise specified, abdominal pain unspecified site, chest pain
not elsewhere classified, syncope and collapse, and fever (Table 5). As above, this list
is nearly identical to the comparable list using the 2005 ED data.
8
5. Geographic Distribution of Patients with Primary Care-Related Visits
• ED visits were mapped according to both frequency and rate. Rates were based on
2005 population estimates provided by Environmental Systems Research Institute,
Inc. ZIP codes having populations below 2,000 were excluded.
• The frequencies of overall ED visits, primary care related ED visits in general, and
primary care related ED visits by persons who were uninsured came from the
following ZIP code clusters (in clockwise order): 1) Aldine/Fifth Ward/northeast
section of the 610 loop (both inside and outside the loop); 2) the Baytown/Ship
Channel area; 3) Galena Park and parts of Pasadena; 4) Third Ward and South
Park/central and southern part of the 610 loop; 5) southwestern/Alief/Sharpstown
area; 6) Bear Creek/intersection of interstate 10 and highway 6; and 7) Acres
Homes/Spring Branch (Maps 1, 2, and 3).
• When examined in terms of population rates, the areas with the highest rates of
overall ED visits, primary care related ED visits in general, and primary care related
ED visits by the uninsured are the east/northeast and south central areas of Harris
County (Maps 4, 5, and 6).
• Tables 6 and 7 show the ZIP code level breakdown for the top ZIP codes for Maps 3
and 6 (respectively). The ZIP codes of 77520 (Baytown), 77026 (Northeast), and
77033 (South Park) are among the highest for both frequency and rate of primary care
related ED visits by the uninsured.
• The data in this aggregate report centers around Harris County area ZIP codes.
However, the hospitals included here also draw patients from a wider area. Maps 7, 8,
9
and 9 reflect the wider eight county geographical distribution of patients, and serve
as complements to Maps 1, 2, and 3 found in the individual hospital reports.
Estimated Cost of Primary Care Related ED Visits By The Uninsured
• The Medical Expenditure Panel Survey (MEPS), part of the federal Agency for
Healthcare Research and Quality, found that in 2003 (the most recent year for
national estimates) the mean cost of an emergency department visit was $560,
whereas the mean cost of an office-based physician visit was $121.
• In 2006, 118,689 primary care related ED visits by Harris County area residents were
by persons who were uninsured (Tables 2 and 3). Using the MEPS estimates, the
estimated cost of those visits was $66,465,840. If those same visits had taken place in
an office based setting, the estimated cost would have been $14,361,369 – a savings
of over $50,000,000 to the community.
• These cost estimates are to be treated with caution for two reasons: 1) The MEPS
estimates are national estimates and are based on all payer sources (e.g. insured and
self pay), as well as on all acuity levels. 2) Actual costs at individual hospitals in this
study may vary.
2002-2006 Comparison
ED visits in eleven hospitals (Ben Taub General, LBJ General, Memorial Hermann Texas Medical Center, Memorial Hermann Southwest, Memorial Hermann Southeast, Memorial Hermann Northwest, Memorial Hermann The Woodlands, Memorial Hermann Memorial City, Memorial Hermann Katy, Memorial Hermann Sugar Land, and St. Joseph Medical Center) have been included in the Harris County study since it began with 2002 data. Beginning in 2005, the ED algorithm was restricted to only those visits where a person was discharged to home or
10
self care.
From 2005 to 2006, among Harris County residents there was a decline in total non hospitalized visits (320,236 to 318,776), total primary care related visits (207,715 to 205,464), percentage of total visits that were primary care related (54.1% to 52.1%), and percentage of categorized visits that were primary care related (83.4% to 80.8%) (Table 8). The analyses here of the original 11 hospitals are restricted to Harris County residents, yet even among residents of the eight county area total non hospitalized visits to the original 11 declined from 390,719 in 2005 to 382,619 in 2006. By contrast, the percentage of total visits that were injuries remained nearly unchanged from 2005 to 2006 (22.9% to 22.8%). Using the aforementioned MEPS estimate, the cost for primary care related ED visits to these 11 hospitals (all payer sources) went from $116,320,400 in 2005 to $115,059,840 in 2006 – a drop of $1,260,560.
In contrast to previous years, commercial insurance and Medicare both increased as payer sources from 2005 to 2006. The uninsured continue to figure predominantly in the payer mix, but the percentage of their visits decreased from 2005 to 2006. Medicaid also decreased as a payer source from 2005 to 2006 (Figure 13). There has been a recent decrease in the number of primary care related ED visits by Hispanics and slight increases by Blacks and Whites. Blacks continue to have the greatest proportion of primary care related ED visits (Figure 14). There was a slight decrease in visits by those under the age of 17 and an increase among those aged 65 or over (Figure 15). There has been no change in the gender ratio (Figure 16).
11
Conclusions
The 2005 and 2006 studies both include the same number of hospitals. The mix of participating hospitals has changed slightly, making an exact comparison tentative. Nevertheless, a few comparisons can be made: 1) From 2005 to 2006, there were declines in the percentage of total non hospitalized visits (53.6% to 51.6%) and categorized visits (82.6% to 81.6%) that are primary care related. Similar declines were found for the original 11 hospitals (see above). Individual hospital changes may vary. More than half of all non hospitalized ED visits are still primary care related. 2) The peak hour for total ED visits and primary care related ED visits continues to be midmorning. This is a time at which outpatient clinics would normally be open. 3) More than three out of ten primary care related ED visits are by those who are uninsured. 4) Close to seven out of ten primary care related ED visits are by persons who are Black or Hispanic. 5) Just under four out of ten primary care related ED visits are by children age 17 or younger. 6) More than half of primary care related ED visits are by female patients. The geographic distribution of primary care related ED visits by the uninsured did not change in 2006, despite the varied locations of the two new hospitals participating in the study. The distribution by population continues to distinguish the east/northeast and south central sections of Harris County as having high rates of primary care related ED visits by the uninsured (Map 6).
Continued participation by a large number of hospitals has allowed for a fuller picture of the nature and distribution of primary care related ED visits. This in turn can allow for more effective planning and policy making, in areas such as where to expand outpatient capacity, nursing triage, patient education about when to use an ED, etc. In a time of limited resources and a large number of persons who are uninsured, the continued high volume of primary care related
12
ED visits represent potential cost savings that might occur from shifting patients to more appropriate settings. Note:
The ED algorithm does not classify hospitalized visits, nor does it classify mental health,
drug/alcohol, and injury visits. It is likely that a large percentage of mental health, drug/alcohol, and injury visits are unavoidable emergency department visits.
13
II. PURPOSE
The increasing number of hospital emergency department visits, many of which are
primary care-related, is leading to a multitude of associated issues regarding equity and access to
care in the U.S. One of the most pressing issues in Houston is the capacity of hospitals to
provide emergency care when emergency rooms are crowded with patients seeking basic care.
The main purpose of this study is to provide information on the frequency, type, and distribution
of ED visits in Houston hospitals that are primary care-related. To achieve this purpose, the
study obtained ED data from twenty five hospitals in Houston for 2006, classified the visits of
Harris County residents in terms of primary care-related/non-primary care-related use of the ED,
and examined the demographic, coverage, and geographic characteristics of patients making the
visits. The goal is to replicate the study over time in order to determine trends and evaluate
primary care enhancement activities.
14
III. METHODS
The study initially resulted from a partnership between Gateway to Care, the Harris
County Hospital District (HCHD), and The University of Texas School of Public Health
(UTSPH). In 2002, UTSPH worked with Gateway to Care on a pilot study to develop a process
for monitoring ED use in Houston. The process developed in the pilot study was then applied to
11 hospitals in 2002. Data were obtained from these hospitals and two others in 2003. In 2004,
data was collected from an additional three hospitals. The current report, using data from 25 of
the hospitals that serve the Houston 911 service area, is the most extensive report of the last four
years. Aggregate reports for each year are posted on the website for the Health Services
Research Collaborative.
The first step in the study involves requesting the following information on ED visits in
Houston hospitals:
1. Date and time of admission to ED 2. Primary and secondary discharge diagnosis 3. Discharge date and time 4. Payment source (payer codes from the Patient Data Set of the Texas Hospital
Association and the Texas Health Care Information Council) 5. Patient age 6. Patient gender 7. Patient race/ethnicity (Black, Asian, American Indian, Hispanic, White, Other,
Unknown) 8. Patient ZIP code 9. Where discharged to (e.g. home, hospital, etc)
Working with the hospitals, a dataset was obtained, reviewed, and cleaned comprising a full set
of ED visit information for the period January 1, 2006 – December 31, 2006. Visits that did not
result in an admission were analyzed.
The second step involved the application of the New York University ED Classification
Algorithm to classify ED visits of Harris County residents into the following four categories:
15
1. Non-emergent: Immediate treatment was not required within 12 hours.
2. Emergent-Primary Care Treatable: Treatment was required within 12 hours, but could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting.
3. Emergent-ED Care Needed-Preventable/Avoidable: ED care was required within
12 hours, but the emergent nature of the condition was potentially preventable/avoidable if timely/continuous primary care had been received for the underlying illness.
4. Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required
within 12 hours and primary care could not have prevented the condition.
The NYU Center for Health and Public Service Research and the United Hospital Fund
of New York developed the ED Algorithm as a measure of primary care-related ED use. The ED
Algorithm is a set of probabilities that when applied to the primary diagnosis (ICD-9 code) of the
patient estimates the likelihood that the patient’s ED visit was one or more of the types described
above. The ED algorithm was developed with the advice of a panel of ED physicians and is
based on information abstracted from a sample of complete ED records – 3,500 cases in 1994
and 2,200 cases in 1999 – from six Bronx, New York hospitals. The decision tree followed by
the panel is summarized on the next page.
The distribution of ED visits by type represents the weighted sum of all visits with a
certain probability of being that type. ED visits in the first three categories are considered
primary care-related use of the ED, while those in the fourth category reflect non-primary care-
related use of the ED. A number of visits are not categorized using the Algorithm. These
include injury, mental health-related, and alcohol or drug-related visits, and visits with missing
data. The ED Algorithm for these visits has not yet been developed by the NYU researchers.
16
Various analyses were conducted of the classified visit data to determine patterns of
primary care-related and non-primary care-related visits. These included monthly, daily, and
time of day patterns of visits; the distribution of visits by the coverage and demographic
characteristics of patients (payment source, race/ethnicity, age, employment status, and sex); the
distribution of visits by primary diagnosis (ICD9 Codes); and the distribution of visits by patient
residence using geo-coded maps.
The results of the analysis of ED visits should be treated cautiously and are best viewed
as indicators of utilization rather than a definitive assessment. This is because only a portion of
all visits that did not result in a hospitalization are collected and only a subset of those visits is
categorized by the Algorithm. ED visits that result in a hospital admission usually encompass no
more than 10-20% of total visits.1 Presumably such visits would not fall into primary care-
related categories nor would most injury visits that are not categorized. Given these limitations
1 Billings J, Using administrative data to monitor access, identify disparities, and assess
performance of the safety net, U.S. Agency for Healthcare Research and Quality, 2003.
Emergent
Non-emergent
ED Care Needed
Primary Care Treatable
Primary Care Treatable
Not Preventable/Avoidable
Preventable/Avoidable
Step 1 Steps 2 and 3 Step 4
ED CLASSIFICATION PROCESS
17
in the methods, the percentage of visits that fall into the primary care-related categories should
be interpreted as a conservative estimate and may underestimate the true value in the population.
18
IV. RESULTS
ED Visits by Type
During 2006, 991,861 total ED visits were made to these 25 hospitals by residents of the
eight county area. Non hospitalized ED visits by residents of the eight county area numbered
780,076. Of this number, 709,496 non hospitalized ED visits were made by Harris County area
residents (Table 1). This report represents 71.53% of all ED visits and 90.95% of non
hospitalized ED visits to these hospitals.
51.6% of all ED visits by Harris County residents in 2006 were primary care-related. This
represents 81.6% of categorized ED visits (Table 1). In 2005, 53.6% of all ED visits were
primary care related, and 82.6% of categorized ED visits were primary care related. The 2006
report thus represents a decline in primary care related ED visits.
One fifth of all ED visits (20.7%) were non-emergent (Table 1). A slightly higher
percentage (22.7%) were primary care treatable. This represents 32.8% and 36.2% respectively,
of categorizable visits (Table 1).
166,872 ED visits (23.5% of total ED visits) were injuries, and 10,466 ED visits (2.2% of
total) were either mental health, alcohol, or drug related (Table 1).
19
Table 1. 2006 Non Hospitalized ED visits at All Hospitals (N=25) by Harris County Area Residents
Type of Visit All
Number 25
CATEGORIZED VISITS
Non-Emergent 146,963
Emergent, Primary Care Treatable 162,192
Emergent, ED Care Needed - Preventable/Avoidable 56,800
Total Primary Care Related Visits 365,955
Emergent, ED Care Needed - NOT Preventable/Avoidable 82,485
Total Categorized Visits 448,440
NON-CATEGORIZED ED VISITS
Injury 166,872
Mental Health Related 10,466
Alcohol or Drug Related 5,297
Unclassified 78,421
Total Non-Categorized Visits 261,056
Total Visits 709,496
Percent
DETAIL - CATEGORIZED ED VISITS
Non-Emergent 32.8%
Emergent - Primary Care Treatable 36.2%
ED Care Needed - Prev./Avoid. 12.7%
% Total Primary Care Related 81.6%
ED Care Needed - NOT Prev./Avoid. 18.4%
TOTAL
Non-Emergent 20.7%
Emergent - Primary Care Treatable 22.9%
ED Care Needed - Prev./Avoid. 8.0%
% Total Primary Care Related 51.6%
ED Care Needed - NOT Prev./Avoid. 11.6%
% Categorized ED Visits 63.2%
Injury 23.5%
Mental Health Related 1.5%
Alcohol or Drug Related 0.7%
Unclassified 11.1%
% All Visits 100.0%
20
Figure 1. Percentage of Categorized ED Visits by Type (N=25)
21
ED Visits by Month, Day of Week, and Time of Day
ED visits by Harris County residents declined during the year, peaking in January at
roughly 42,000, with August having the fewest visits. The summer months overall had the fewest
ED visits (Figure 2). Primary care-related ED visits followed roughly the same pattern.
There was almost no variation in the number of total ED visits by day of the week. The
exception was a peak on Wednesday (Figure 3).
The smallest number of ED visits were between the hours of 4 AM and 6 AM, the most
were between the hours of 11 AM and 8 PM (this pattern is unchanged from 2005). Primary
care-related ED visits followed a similar pattern (Figure 4). It should be noted that a large
volume of primary care-related ED visits occurred during hours in which physicians’ offices and
outpatient clinics would normally be open.
22
Figure 2
23
Figure 3
24
Figure 4
25
Primary Care-Related ED Visits by Patient Characteristics
32.4% of primary care-related visits were by patients who were uninsured (32.9% in
2005), 25.8% had Medicaid (30.8% in 2005), 30.1% had private insurance (24.8% in 2005), and
9.2% had Medicare (8.6% in 2005) (Figure 5).
34.4% of primary care-related visits were by Blacks, 32.5% Hispanics, 25.7% Whites,
2.3 Other, and 1.3% Asian (Figure 6).
54.3% of primary care-related visits were by adults age 18-64, 38.1% were children and
youth age 0-17, and 7.6% were adults aged 65 or older (Figure 7).
57.6% of primary care-related visits were by females and 42.4% were by males (Figure
8).
Patients with Medicaid had the highest proportion of ED visits that were primary care-
related (77.3%), with patients on Medicare having the lowest proportion at 74.3%. 84.5% of ED
visits by the uninsured were primary care-related, an increase from 2005 (Figure 9).
Race/ethnicity groups with the highest proportion of visits primary care-related were
Blacks (83.9%) and Hispanics 82.6% (Figure 10).
The proportion of visits that were primary care-related declined with age: 88.1% for
children age 17 and younger, 78.9% for adults age 18 to 64, and 72.7% for adults age 65 and
over (Figure 11). The same decline by age was also seen in 2005.
There was almost no variation by gender for proportion of visits that were primary care-
related. However, a higher proportion of women than men had visits that were considered non
emergent (Figure 12).
26
Table 2. ED Visit Types by Coverage and Demographic Characteristics of Patients (N=25)
T ype o f Visit Read Horizontally
C o mm M 'caid M 'care Oth Go v.Oth
P riv.Unins Unk A ll C o mm M 'ca id M 'care
Oth.
Go v
Oth.
P rivUnins
Unis &
M 'caid
Non-Emergent 43,693 35,010 11,667 2,790 1,328 50,864 1,612 146,963 29.7% 23.8% 7.9% 1.9% 0.9% 34.6% 58.4%
Emergent-Primary Care Treatable 50,411 41,673 14,331 3,112 930 51,058 677 162,192 31.1% 25.7% 8.8% 1.9% 0.6% 31.5% 57.2%
Emergent Care Needed-Preventable/Avoidable 15,938 14,888 7,693 1,137 224 16,767 154 56,800 28.1% 26.2% 13.5% 2.0% 0.4% 29.5% 55.7%
T o tal P rimary C are R elated 110,041 91,571 33 ,690 7,038 2,482 118,689 2,443 365,955 30.1% 25.0% 9.2% 1.9% 0.7% 32.4% 57.5%
Emergent C are N eeded-N OT P reventable/ A vo idable29,840 14,494 11,677 1,903 506 23,412 654 82,485 36.2% 17.6% 14.2% 2.3% 0.6% 28.4% 46.0%
TOTAL Categorized Visits 139,881 106,065 45,367 8,941 2,988 142,101 3,097 448,440 31.2% 23.7% 10.1% 2.0% 0.7% 31.7% 55.3%
TOTAL All Visits 231,683 149,425 74,371 18,483 9,666 218,258 7,610 709,496 32.7% 21.1% 10.5% 2.6% 1.4% 30.8% 51.8%
A sian B lack H isp. A m. Ind. Other Unk White A ll A sian B lack H ispanicA m.
IndianOther Unk White
Non-Emergent 2,077 51,285 48,288 80 3,386 5,441 36,407 146,963 1.4% 34.9% 32.9% 0.1% 2.3% 3.7% 24.8%
Emergent-Primary Care Treatable 2,073 53,436 54,187 91 3,850 6,226 42,330 162,192 1.3% 32.9% 33.4% 0.1% 2.4% 3.8% 26.1%
Emergent Care Needed-Preventable/Avoidable 651 21,261 16,433 35 1,315 1,712 15,393 56,800 1.1% 37.4% 28.9% 0.1% 2.3% 3.0% 27.1%
T o tal P rimary C are R elated 4,801 125,982 118,909 206 8,550 13,378 94,129 365,955 1.3% 34.4% 32.5% 0.1% 2.3% 3.7% 25.7%
Emergent C are N eeded-N OT P reventable/ A vo idable1,315 24,117 25 ,007 51 2,224 2,494 27,277 82,485 1.6% 29.2% 30.3% 0.1% 2.7% 3.0% 33.1%
TOTAL Categorized Visits 6,116 150,099 143,916 257 10,774 15,872 121,406 448,440 1.4% 33.5% 32.1% 0.1% 2.4% 3.5% 27.1%
TOTAL All Visits 10,158 218,469 218,849 419 17,811 29,463 214,327 709,496 1.4% 30.8% 30.8% 0.1% 2.5% 4.2% 30.2%
0-17 18-64 65+ A ll 0-17 18-64 65+
Non-Emergent 52,448 84,958 9,558 146,963 35.7% 57.8% 6.5%
Emergent-Primary Care Treatable 64,430 85,876 11,886 162,192 39.7% 52.9% 7.3%
Emergent Care Needed-Preventable/Avoidable 22,514 28,053 6,233 56,800 39.6% 49.4% 11.0%
T o tal P rimary C are R elated 139,391 198,886 27 ,677 365,955 38.1% 54.3% 7.6%
Emergent C are N eeded-N OT P reventable/ A vo idable18,900 53,182 10,404 82,485 22.9% 64.5% 12.6%
TOTAL Categorized Visits 158,291 252,068 38,081 448,440 35.3% 56.2% 8.5%
TOTAL All Visits 238,944 407,297 63,255 709,496 33.7% 57.4% 8.9%
F emale M ale Unk A ll F emale M ale Unk
Non-Emergent 88,459 58,500 5 146,963 60.2% 39.8% 0.0%
Emergent-Primary Care Treatable 92,143 70,042 7 162,192 56.8% 43.2% 0.0%
Emergent Care Needed-Preventable/Avoidable 30,320 26,476 3 56,800 53.4% 46.6% 0.0%
T o tal P rimary C are R elated 210,922 155,017 15 365,955 57.6% 42.4% 0.0%
Emergent C are N eeded-N OT P reventable/ A vo idable47,726 34,757 3 82,485 57.9% 42.1% 0.0%
TOTAL Categorized Visits 258,648 189,774 18 448,440 57.7% 42.3% 0.0%
TOTAL All Visits 388,367 321,099 30 709,496 54.7% 45.3% 0.0%
P A YM EN T SOUR C E
A GE
GEN D ER
R A C E/ ET H N IC IT Y
27
Figure 5. Primary Care Related ED Visits by Payment Source (N=25)
Figure 6. Primary Care Related ED Visits by Race/Ethnicity (N=25)
28
Figure 7. Primary Care Related ED Visits by Age (N=25)
Figure 8. Primary Care Related ED Visits by Gender (N=25)
29
Table 3. Coverage and Demographic Characteristics of Patients by ED Visit Type (N=25)
T ype o f V isit
C o mm M 'caid M 'careOther
Go v.
Other
P riv.Unins Unk A ll C o mm. M 'caid M 'care
Oth
Go v.
Oth
P riv.Unins. A ll
Non-Emergent 43,693 35,010 11,667 2,790 1,328 50,864 1,612 146,963 31.2% 33.0% 25.7% 31.2% 44.4% 35.8% 32.8%
Emergent-Primary Care Treatable 50,411 41,673 14,331 3,112 930 51,058 677 162,192 36.0% 39.3% 31.6% 34.8% 31.1% 35.9% 36.2%
Emergent Care Needed-Preventable/Avoidable 15,938 14,888 7,693 1,137 224 16,767 154 56,800 11.4% 14.0% 17.0% 12.7% 7.5% 11.8% 12.7%
T o tal P rimary C are R elated 110,041 91,571 33,690 7,038 2,482 118,689 2,443 365,955 78.7% 86.3% 74.3% 78.7% 83.1% 83.5% 81.6%
Emergent C are N eeded-N OT P reventable/ A vo idable29,840 14,494 11,677 1,903 506 23,412 654 82,485 21.3% 13.7% 25.7% 21.3% 16.9% 16.5% 18.4%
TOTAL Categorized Visits 139,881 106,065 45,367 8,941 2,988 142,101 3,097 448,440 31.2% 23.7% 10.1% 2.0% 0.7% 31.7% 100.0%
TOTAL All Visits 231,683 149,425 74,371 18,483 9,666 218,258 7,610 709,496 32.7% 21.1% 10.5% 2.6% 1.4% 30.8% 100.0%
A sian B lack H isp. A m. Ind. Oth Unk White A ll A sian B lack H isp. A m.Ind. Oth Unk White A ll
Non-Emergent 2,077 51,285 48,288 80 3,386 5,441 36,407 146,963 34.0% 34.2% 33.6% 31.0% 31.4% 34.3% 30.0% 32.8%
Emergent-Primary Care Treatable 2,073 53,436 54,187 91 3,850 6,226 42,330 162,192 33.9% 35.6% 37.7% 35.5% 35.7% 39.2% 34.9% 36.2%
Emergent Care Needed-Preventable/Avoidable 651 21,261 16,433 35 1,315 1,712 15,393 56,800 10.6% 14.2% 11.4% 13.6% 12.2% 10.8% 12.7% 12.7%
T o tal P rimary C are R elated 4,801 125,982 118,909 206 8,550 13,378 94,129 365,955 78.5% 83.9% 82.6% 80.2% 79.4% 84.3% 77.5% 81.6%
Emergent C are N eeded-N OT P reventable/ A vo idable1,315 24,117 25,007 51 2,224 2,494 27,277 82,485 21.5% 16.1% 17.4% 19.8% 20.6% 15.7% 22.5% 18.4%
TOTAL Categorized Visits 6,116 150,099 143,916 257 10,774 15,872 121,406 448,440 1.4% 33.5% 32.1% 0.1% 2.4% 3.5% 27.1% 100.0%
TOTAL All Visits 10,158 218,469 218,849 419 17,811 29,463 214,327 709,496 1.4% 30.8% 30.8% 0.1% 2.5% 4.2% 30.2% 100.0%
0-17 18-64 65+ A ll 0-17 18-64 65+ A ll
Non-Emergent 52,448 84,958 9,558 146,963 33.1% 33.7% 25.1% 32.8%
Emergent-Primary Care Treatable 64,430 85,876 11,886 162,192 40.7% 34.1% 31.2% 36.2%
Emergent Care Needed-Preventable/Avoidable 22,514 28,053 6,233 56,800 14.2% 11.1% 16.4% 12.7%
T o tal P rimary C are R elated 139,391 198,886 27,677 365,955 88.1% 78.9% 72.7% 81.6%
Emergent C are N eeded-N OT P reventable/ A vo idable18,900 53,182 10,404 82,485 11.9% 21.1% 27.3% 18.4%
TOTAL Categorized Visits 158,291 252,068 38,081 448,440 35.3% 56.2% 8.5% 100.0%
TOTAL All Visits 238,944 407,297 63,255 709,496 33.7% 57.4% 8.9% 100.0%
F emale M ale Unk A ll F emale M ale A ll
Non-Emergent 88,459 58,500 5 146,963 34.2% 30.8% 32.8%
Emergent-Primary Care Treatable 92,143 70,042 7 162,192 35.6% 36.9% 36.2%
Emergent Care Needed-Preventable/Avoidable 30,320 26,476 3 56,800 11.7% 14.0% 12.7%
T o tal P rimary C are R elated 210,922 155,017 15 365,955 81.5% 81.7% 81.6%
Emergent C are N eeded-N OT P reventable/ A vo idable47,726 34,757 3 82,485 18.5% 18.3% 18.4%
TOTAL Categorized Visits 258,648 189,774 18 448,440 57.7% 42.3% 100.0%
TOTAL All Visits 388,367 321,099 30 709,496 54.7% 45.3% 100.0%
P A YM EN T SOUR C E read vertically
A GE
SEX
R A C E/ ET H N IC IT Y
30
Figure 9. Payment Source by ED Visit Type (N=25)
31.2% 33.0%25.7%
31.2%
44.4%35.8% 32.8%
36.0%39.3%
31.6%
34.8%
31.1%
35.9%36.2%
11.4%
14.0%
17.0%
12.7%
7.5% 11.8%12.7%
21.3%13.7%
25.7%21.3%
16.9% 16.5% 18.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Emergent Care Needed-NOT
Preventable/Avoidable
Emergent Care Needed-
Preventable/Avoidable
Emergent-Primary Care
Treatable
Non-Emergent
31
Figure 10. Race/Ethnicity by ED Visit Type (N=25)
34.0% 34.2% 33.6% 31.0% 31.4% 34.3%30.0% 32.8%
33.9% 35.6% 37.7%35.5% 35.7%
39.2%
34.9%36.2%
10.6%14.2% 11.4%
13.6% 12.2%
10.8%
12.7%12.7%
21.5%16.1% 17.4% 19.8% 20.6%
15.7%22.5%
18.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Emergent Care Needed-
NOT Preventable/Avoidable
Emergent Care Needed-
Preventable/Avoidable
Emergent-Primary Care
Treatable
Non-Emergent
32
Figure 11. Age by ED Visit Type (N=25)
33.1% 33.7%25.1%
32.8%
40.7%34.1%
31.2%
36.2%
14.2%
11.1%
16.4%
12.7%
11.9%
21.1%27.3%
18.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-17 18-64 65+ All
Emergent Care Needed-NOT
Preventable/Avoidable
Emergent Care Needed-
Preventable/Avoidable
Emergent-Primary Care
Treatable
Non-Emergent
33
Figure 12. Gender by ED Visit Type (N=25)
34.2% 30.8% 32.8%
35.6%36.9% 36.2%
11.7% 14.0% 12.7%
18.5% 18.3% 18.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Female Male All
Emergent Care Needed-
NOT Preventable/Avoidable
Emergent Care Needed-
Preventable/Avoidable
Emergent-Primary Care
Treatable
Non-Emergent
34
Health Conditions of Patients with Primary and Non-Primary Care-Related Visits
The five most frequent diagnoses of patients with primary care-related visits were: acute
upper respiratory infection not otherwise specified, otitis media not otherwise specified, fever,
noninfectious gastroenteritis, and urinary tract infection not otherwise specified (Table 4). A
comparison with the ED report using the 2005 data shows the same top results, although in a
slightly different order.
The five most frequent diagnoses of patients with non-primary care related ED visits
were chest pain not otherwise specified, abdominal pain unspecified site, chest pain not
elsewhere classified, syncope and collapse, and fever (Table 5). As above, this list is nearly
identical to the comparable list using the 2005 ED data.
35
Table 4. Most Frequent Conditions of Patients with Primary Care Related ED Visits (N=25)
Obs Icd COUNT Description
1 4659 18,247 acute uri nos
2 3829 14,870 otitis media nos
3 7806 13,069 fever
4 5589 12,277 noninf gastroenterit nec
5 5990 12,137 urin tract infection nos
6 462 10,220 acute pharyngitis
7 486 8,744 pneumonia, organism nos
8 7840 8,644 headache
9 49392 7,599 asthma nos w(ac) exacerb
10 78039 7,438 convulsions nec
11 78900 7,348 abdmnal pain unspcf site
12 6826 6,718 cellulitis of leg
13 78703 6,143 vomiting alone
14 4019 5,810 hypertension nos
15 78659 5,684 chest pain nec
16 7999 5,532 viral infection nos
17 64893 5,142 oth curr cond-antepartum
18 7242 5,067 lumbago
19 490 5,039 bronchitis nos
20 7804 4,741 dizziness and giddiness
21 7295 4,642 pain in limb
22 4660 4,554 acute bronchitis
23 V642 4,322 no proc/patient decision
24 78652 3,848 painful respiration
25 64003 3,477 threaten abort-antepart
36
Table 5. Most frequent Conditions of Patients with Non Primary Care Related ED Visits (N=25)
Obs Icd COUNT Description
1 78650 5,903 chest pain nos
2 78900 3,623 abdmnal pain unspcf site
3 78659 3,617 chest pain nec
4 7802 3,365 syncope and collapse
5 7806 3,187 fever
6 5921 3,012 calculus of ureter
7 5920 1,803 calculus of kidney
8 64003 1,739 threaten abort-antepart
9 78909 1,580 abdmnal pain oth spcf st
10 V715 1,536 observ following rape
11 5409 1,471 acute appendicitis nos
12 7851 1,329 palpitations
13 78703 1,316 vomiting alone
14 7840 1,290 headache
15 4644 1,226 croup
16 42731 1,219 atrial fibrillation
17 5770 1,198 acute pancreatitis
18 46619 1,149 acu brnchlts d/t oth org
19 57420 1,087 cholelithiasis nos
20 4359 1,074 trans cereb ischemia nos
21 53550 1,048 gstr/ddnts nos w/o hmrhg
22 56211 1,028 dvrtcli colon w/o hmrhg
23 28262 942 hb-s disease with crisis
24 78906 878 abdmnal pain epigastric
25 5789 829 gastrointest hemorr nos
37
Geographic Distribution of Patients with Primary Care-Related Visits
ED visits were mapped according to both frequency and rate. Rates were based on 2005
population estimates provided by Environmental Systems Research Institute, Inc. ZIP codes
having populations below 2,000 were excluded.
The frequencies of overall ED visits, primary care related ED visits in general, and
primary care related ED visits by persons who were uninsured came from the following ZIP code
clusters (in clockwise order): 1) Aldine/Fifth Ward/northeast section of the 610 loop (both inside
and outside the loop); 2) the Baytown/Ship Channel area; 3) Galena Park and parts of Pasadena;
4) Third Ward and South Park/central and southern part of the 610 loop; 5) southwestern
(Alief/Sharpstown) area; 6) Bear Creek/intersection of interstate 10 and highway 6; and 7) Acres
Homes/Spring Branch (Maps 1, 2, and 3).
When examined in terms of population rates, the areas with the highest rates of overall
ED visits, primary care related ED visits in general, and primary care related ED visits by the
uninsured are the east/northeast and south central areas of Harris County (Maps 4, 5, and 6).
Tables 6 and 7 show the ZIP code level breakdown for the top ZIP codes for Maps 3 and
6 (respectively). The ZIP codes of 77520 (Baytown), 77026 (Northeast), and 77033 (South Park)
are among the highest for both frequency and rate of primary care related ED visits by the
uninsured.
The data in this aggregate report centers around Harris County area ZIP codes. However, the hospitals included here also draw patients from a wider area. Maps 7, 8, and 9 reflect the
wider geographical distribution of patients, and serve as complements to Maps 1, 2, and 3 in the
individual hospital reports.
38
Map 1
39
Map 2
40
Map 3
41
Map 4
42
Map 5
43
Map 6
44
Table 6. Harris County ZIP codes in 2006 with highest frequency of primary care related visits by the uninsured (see Map 3)
ZIP Total Approx. area
77520 3,535 Baytown
77015 3,385 Ship Channel
77036 2,825 Southwest
77521 2,316 Baytown
77072 2,190 Southwest
77506 1,938 Pasadena
77093 1,889 Fifth Ward/Northeast
77026 1,852 Northeast/LBJ Area
77055 1,839 Spring Branch
77033 1,827 South Park
Table 7. Harris County ZIP codes in 2006 with highest rate of primary care related visits by the uninsured (see Map 6)
ZIP Rate per 1,000 Approx. area
77002 79.35 Downtown
77051 73.15 Outside South Loop
77028 66.76 Northeast/LBJ Area
77078 66.19 Northeast
77520 65.99 Baytown
77026 62.43 Northeast/LBJ Area
77033 60.68 South Park
77015 60.29 Ship Channel
77048 57.98 South Central Harris County
77049 56.15 Northeast/Ship Channel
45
Map 7
46
Map 8
47
Map 9
48
2002-2006 Comparison
ED visits in eleven hospitals (Ben Taub General, LBJ General, Memorial Hermann Texas Medical Center, Memorial Hermann Southwest, Memorial Hermann Southeast, Memorial Hermann Northwest, Memorial Hermann The Woodlands, Memorial Hermann Memorial City, Memorial Hermann Katy, Memorial Hermann Sugar Land, and St. Joseph Medical Center) have been included in the Harris County study since it began with 2002 data. Beginning in 2005, the ED algorithm was restricted to only those visits where a person was discharged to home or self care.
From 2005 to 2006, among Harris County residents there was a decline in total non hospitalized visits (320,236 to 318,776), total primary care related visits (207,715 to 205,464), percentage of total visits that were primary care related (54.1% to 52.1%), and percentage of categorized visits that were primary care related (83.4% to 80.8%) (Table 8). The analyses here of the original 11 hospitals are restricted to Harris County residents, yet even among residents of the eight county area total non hospitalized visits to the original 11 declined from 390,719 in 2005 to 382,619 in 2006. By contrast, the percentage of total visits that were injuries remained nearly unchanged from 2005 to 2006 (22.9% to 22.8%). Using the aforementioned MEPS estimate, the cost for primary care related ED visits to these 11 hospitals (all payer sources) went from $116,320,400 in 2005 to $115,059,840 in 2006 – a drop of $1,260,560.
Commercial insurance and Medicare both increased as payer sources from 2005 to 2006. The uninsured continue to figure predominantly in the payer mix, but the percentage of their visits decreased from 2005 to 2006. Medicaid decreased as a payer source (Figure 13). There has been a recent decrease in the number of primary care related ED visits by Hispanics and slight increases by Blacks and Whites. Blacks continue to have the greatest
49
proportion of primary care related ED visits (Figure 14). There was a slight decrease in visits by those under the age of 17 and an increase among those aged 65 or over (Figure 15). There has been no change in the gender ratio (Figure 16).
50
Table 8. 2002-2006 ED Visits at Eleven Hospitals by Harris County Residents
* Analyses restricted to persons discharged to home or self care.
Type of Visit 2002 2003 2004 2005* 2006*
Number 11 11 11 11 11
CATEGORIZED VISITS
Non-Emergent 103,205 110,722 101,965 76,487 70,175
Emergent, Primary Care Treatable 103,377 109,885 93,447 74,034 70,544
Emergent, ED Care Needed - Preventable/Avoidable 36,371 38,340 28,229 22,679 25,230
Total Primary Care Related Visits 242,953 258,947 223,641 173,200 165,948
Emergent, ED Care Needed - NOT Preventable/Avoidable 55,293 57,130 44,108 34,515 39,516
Total Categorized Visits 298,246 316,077 267,749 207,715 205,464
NON-CATEGORIZED ED VISITS
Injury 107,025 109,032 92,884 73,472 72,587
Mental Health Related 7,660 7,901 7,762 5,694 5,266
Alcohol or Drug Related 4,107 3,854 3,446 2,757 3,261
Unclassified 48,871 49,018 36,358 30,598 32,198
Total Non-Categorized Visits 167,663 169,805 140,450 112,521 113,312
Total Visits 465,909 485,882 408,199 320,236 318,776
Percent
DETAIL - CATEGORIZED ED VISITS
Non-Emergent 34.6% 35.0% 38.1% 36.8% 34.2%
Emergent - Primary Care Treatable 34.7% 34.8% 34.9% 35.6% 34.3%
ED Care Needed - Prev./Avoid. 12.2% 12.1% 10.5% 10.9% 12.3%
% Primary Care Related Visits 81.5% 81.9% 83.5% 83.4% 80.8%
ED Care Needed - NOT Prev./Avoid. 18.5% 18.1% 16.5% 16.6% 19.2%
TOTAL ED VISITS
Non-Emergent 22.2% 22.8% 25.0% 23.9% 22.0%
Emergent - Primary Care Treatable 22.2% 22.6% 22.9% 23.1% 22.1%
ED Care Needed - Prev./Avoid. 7.8% 7.9% 6.9% 7.1% 7.9%
% Primary Care Related Visits 52.1% 53.3% 54.8% 54.1% 52.1%
ED Care Needed - NOT Prev./Avoid. 11.9% 11.8% 10.8% 10.8% 12.4%
% Categorized ED Visits 64.0% 65.1% 65.6% 64.9% 64.5%
Injury 23.0% 22.4% 22.8% 22.9% 22.8%
Mental Health Related 1.6% 1.6% 1.9% 1.8% 1.7%
Alcohol or Drug Related 0.9% 0.8% 0.8% 0.9% 1.0%
Unclassified 10.5% 10.1% 8.9% 9.6% 10.1%
% All Visits 100.0% 100.0% 100.0% 100.0% 100.0%
51
Figure 13. 2002-2006 Primary Care Related ED Visits by Payer Source
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
2002
2003
2004
2005
2006
Figure 14. 2002-2006 Primary Care Related ED Visits by Race/Ethnicity
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
2002
2003
2004
2005
2006
52
Figure 15. 2002-2006 Primary Care Related ED Visits by Age
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
2002 2003 2004 2005 2006
0-17
18-64
65+
Figure 16. 2002-2006 Primary Care Related ED Visits by Gender
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
2002 2003 2004 2005 2006
Female
Male