Do Adult Medicaid Enrollees Prefer Going to Their Primary Care Provider's Clinic Rather Than Emergency Department (ED) for Low Acuity Conditions?

Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children

OBJECTIVE

To describe racial inequities in pediatric inflammatory bowel disease care and explore potential drivers.

METHODS

We undertook a single-center, comparative cohort study of newly diagnosed Black and non-Hispanic White patients with inflammatory bowel disease, aged <21 years, from January 2013 through 2020. Primary outcome was corticosteroid-free remission (CSFR) at 1 year. Other longitudinal outcomes included sustained CSFR, time to anti-tumor necrosis factor therapy, and evaluation of health service utilization.

RESULTS

Among 519 children (89% White, 11% Black), 73% presented with Crohn's disease and 27% with ulcerative colitis. Disease phenotype did not differ by race. More patients from Black families had public insurance (58% vs 30%, P < .001). Black patients were less likely to achieve CSFR 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). When adjusted by insurance type, differences by race to 1-year CSFR were no longer significant (aOR: 0.58; 95% CI: 0.33, 1.04; P = .07). Black patients were more likely to transition from remission to a worsened state, and less likely to transition to remission. We found no differences in biologic therapy utilization or surgical outcomes by race. Black patients had fewer gastroenterology clinic visits and 2-fold increased odds for emergency department visits.

CONCLUSIONS

We observed no differences by race in phenotypic presentation and medication usage. Black patients had half the odds of achieving clinical remission, but a degree of this was mediated by insurance status. Understanding the cause of such differences will require further exploration of social determinants of health.

Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study

AIMS AND OBJECTIVES

We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation.

BACKGROUND

Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid.

DESIGN

We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study.

METHODS

Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit.

RESULTS

Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01).

CONCLUSIONS

Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid.

RELEVANCE TO CLINICAL PRACTICE

Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.

Multimorbidity clustering of the emergency department patient flow: Impact analysis of new unscheduled care clinics

Background

In France, the number of emergency department (ED) admissions doubled between 1996 and 2016. To cope with the resulting crowding situation, redirecting patients to new healthcare services was considered a viable solution which would spread demand more evenly across available healthcare delivery points and render care more efficient. The objective of this study was to analyze the impact of opening new on-demand care services based on variations in patient flow at a large hospital emergency department.

Methods

We performed a before-and-after study investigating the use of unscheduled care services in the Aube region in eastern France, that focused on ED attendance at Troyes Hospital. A hierarchical clustering based on co-occurrence of diagnoses was applied which divided the population into different multimorbidity profiles. Temporal trends of the resultant clusters were also studied empirically and using regression models. A multivariate logistic regression model was constructed to adjust the periodic effect for appropriate confounders and therefore confirm its presence.

Results

In total, 120,722 visits to the ED were recorded over a 24-month period (2018–2019) and 16 clusters were identified, accounting for 94.76% of all visits. There was a decrease of 56.77 visits per week in seven specific clusters and an increase of use of unscheduled health care services by 328.12 visits per week.

Conclusions

Using an innovative and reliable methodology to evaluate changes in patient flow through the ED, these findings may help inform public health policy experts on the implementation of unscheduled care services to ease pressure on hospital EDs.

Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial

BACKGROUND

Some Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.

OBJECTIVES

To determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.

METHODS

We conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4-18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.

RESULTS

Of 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (-$10,201, p = 0.10); Medicaid costs were unchanged (-$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).

CONCLUSION

An ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.

Emergency Department and Primary Care Use in Massachusetts 5 Years After Health Reform

OBJECTIVE

Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees.

POPULATION AND SETTING

People under age 65 in the Massachusetts All-Payer Claims Data, 2011-2012.

STUDY DESIGN

Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records.

PRINCIPAL FINDINGS

Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49-2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one's own (attributed) primary care provider (38% vs. 44%).

CONCLUSIONS

Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.

Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs

Background: An underlying assumption of strategies intended to promote appropriate primary care over emergency department (ED) use for ongoing health care needs is that patients will understand the “value proposition” of primary care: that they will receive specific benefits from primary care providers over and above what they receive from EDs. However, there is evidence that this value proposition may be unclear to safety-net patients. The goals of this study are to describe factors motivating ED use for low-acuity conditions; describe similarities and differences in usual source of care (USOC) experiences, by ED versus non-ED setting; and assess awareness and perceptions of the patient-centered medical home (PCMH) concept among safety-net patients. Methods: We conducted a cross-sectional descriptive study of adult patients (n = 329) at 3 safety-net hospitals in the Southwest. Results: Key reasons for ED use were perceived urgency, lack of awareness about other options for care, payment flexibility, and perceived quality and convenience. Approximately half of participants indicated they would seek treatment in non-ED settings, if available, but agreement differed by group (non-ED USOC, 60.2%; ED USOC, 50.7%; no USOC, 45.3%; P = .025). Agreement that providers coordinated access to needed medical services was significantly higher among patients with non-ED USOCs; agreement that providers coordinated non-medical services that facilitate access to care was similar (approximately 45%) for patients with ED and non-ED USOCs. Approximately 70% of participants in both groups agreed that every person should have a medical home. Conclusions: Perceived experiences of care in ED and non-ED USOC settings suggest challenges and opportunities for increasing the value proposition of primary care for safety-net patients. Although patients are receptive to the PCMH concept, effective strategies to better highlight the value of primary care in coordinating both medical and related nonmedical services and other PCMH benefits warrant further investigation.

Postdischarge Clinics and Hospitalists: A Review of the Evidence and Existing Models

Over the past 10 years, postdischarge clinics have been introduced in response to various health system pressures, including the focus on rehospitalizations and the challenges of primary care access. Often ignored in the discussion are questions of the effect of postdischarge physician visits on readmissions. In addition, little attention has been given to other clinical outcomes, such as reducing preventable harm and mortality. A review of dedicated, hospitalist-led postdischarge clinics, of the data supporting postdischarge physician visits, and of the role of hospitalists in these clinics may be instructive for hospitalists and health systems considering the postdischarge clinic environment. Journal of Hospital Medicine 2017;12:467-471.

Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data

The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.