Association of Medicare and Medicaid insurance with increasing primary care-treatable emergency department visits in the United States

Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults

OBJECTIVE

Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners.

METHODS

Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups.

RESULTS

The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs.

CONCLUSIONS

Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.

Is the emergency department used as a substitute or a complement to primary care in Medicaid?

Policies to decrease low-acuity emergency department (ED) use have traditionally assumed that EDs are a substitute for unavailable primary care (PC). However, such policies can exacerbate ED overcrowding, rather than ameliorate it, if patients use EDs to complement, rather than substitute, their PC use. We tested whether Medicaid managed care enrolees visit the ED for nonemergent and PC treatable conditions to substitute for or to complement PC. Based on consumer choice theory, we modelled county-level monthly ED visit rate as a function of PC supply and used 2012-2015 New York Statewide Planning and Research Cooperative System (SPARCS) outpatient data and non-linear least squares method to test substitution vs complementarity. In the post-Medicaid expansion period (2014-2015), ED and PC are substitutes state-wide, but are complements in highly urban and poorer counties during nights and weekends. There is no evidence of complementarity before the expansion (2012-2013). Analyses by PC provider demonstrate that the relationship between ED and PC differs depending on whether PC is provided by physicians or advanced practice providers. Policies to reduce low-acuity ED use via improved PC access in Medicaid are likely to be most effective if they focus on increasing actual appointment availability, ideally by physicians, in areas with low PC provider supply. Different aspects of PC access may be differently related to low-acuity ED use.

A mobile integrated health program for the management of undifferentiated acute complaints in older adults is safe and feasible

BACKGROUND

Poor care access and lack of proper triage of medical complaints leads to inappropriate use of acute care resources. Mobile integrated health (MIH) programs may offer a solution by providing adaptable on-demand care. There is little information describing programs that manage undifferentiated complaints in the community. The objective of this study was to assess the safety and feasibility of an MIH program that responds to the community to manage medical complaints in older adults.

METHODS

This was a prospective observational study examining a pilot MIH program. Seven ambulatory clinics and their affiliated patients aged 65 and older were oriented to the program and invited to use its services. Visit and follow-up data for all patients who underwent an MIH visit were abstracted, along with 30-day follow-up information. All demographic data and outcomes were reported descriptively.

RESULTS

In 21 months, 153 MIH visits were completed, involving 91 patients (mean age 81 years, 60.4% female). The most common chief complaints were generalized weakness (28.8%) and shortness of breath (18.9%). Electrocardiogram (57.5%) and point-of-care bloodwork (34.6%) were the most common diagnostic tests performed. Sixteen visits (10.4%) were followed by an emergency department (ED) visit within 72 h. In 11 encounters, the patient was referred to the ED; in five cases, the ED visit was unforeseen. Fifteen patients (9.8%) were admitted to the hospital after an MIH visit. There were two deaths within 30 days following an index visit.

CONCLUSIONS

An MIH program designed to address the acute complaints of community-dwelling older adults was feasible and safe, with low rates of unforeseen emergency services utilizations. MIH programs have valuable diagnostic and therapeutic capabilities and may serve to help triage the acute medical needs of patients. Further study is required to validate the efficacy and cost-effectiveness of MIH programs.

Association of Medicaid expansion with dental emergency department visits overall and by states' Medicaid dental benefits provision

BACKGROUND

Evidence on the association of Medicaid expansion with dental emergency department (ED) utilization is limited, while even less is known on policy-related changes in dental ED visits by Medicaid programs' dental benefits generosity. The objective of this study was to estimate the association of Medicaid expansion with changes in dental ED visits overall and by states' benefits generosity.

METHODS

We used the Healthcare Cost and Utilization Project's Fast Stats Database from 2010 to 2015 for non-elderly adults (19 to 64 years of age) across 23 States, 11 of which expanded Medicaid in January 2014 while 12 did not. Difference-in-differences regression models were used to estimate changes in dental-related ED visits overall and further stratified by states' dental benefit coverage in Medicaid between expansion and non-expansion States.

RESULTS

After 2014, dental ED visits declined by 10.9 [95% confidence intervals (CI): -18.5 to -3.4] visits per 100,000 population quarterly in states that expanded Medicaid compared to non-expansion states. However, the overall decline was concentrated in Medicaid expansion states with dental benefits. In particular, among expansion states, dental ED visits per 100,000 population declined by 11.4 visits (95% CI: -17.9 to -4.9) quarterly in states with dental benefits in Medicaid compared to states with emergency-only or no dental benefits. Significant differences between non-expansion states by Medicaid's dental benefits generosity were not observed [6.3 visits (95% CI: -22.3 to 34.9)].

CONCLUSIONS

Our findings suggest the need to strengthen public health insurance programs with more generous dental benefits to curtail costly dental ED visits.

Safety and Feasibility of Performing Antireflux Procedures at a Safety Net Hospital

INTRODUCTION

One-half of Americans have limited access to health care; these patients often receive care through safety net hospitals, which are associated with worse medical outcomes. This study aims to compare the outcomes of patients who received foregut surgery at a safety net hospital to those at a private or university hospital. We hypothesized that patients treated at the safety net hospital will have a greater rate of radiographic recurrence and reoperations.

METHODS

A retrospective study was conducted on patients who underwent hiatal hernia repair or fundoplication for gastroesophageal reflux disease at an affiliated safety net, private, or university hospital from June 2015 to May 2020. The primary outcome was radiographic recurrence. The secondary outcomes included reoperation and symptom recurrence. Analysis was performed using analysis of variance, chi-square, and logistic regression.

RESULTS

A total of 499 patients were identified: 157 at a safety net hospital, 233 at a private hospital, and 119 at a university hospital. The median (interquartile range) follow-up was 16 (13) mo. The safety net hospital treated more Hispanics, females, and patients with comorbidities. Large hiatal hernias were more common at the safety net and private hospitals. Robotic surgery was more frequently at the university hospital. There was no difference in radiographic recurrence (13.4% versus 19.7% versus 17.6%; P = 0.269), reoperation (3.8% versus 7.2% versus 6.7%; P = 0.389), or postoperative dysphagia (15.3% versus 12.6% versus 15.1%; P = 0.696). On logistic regression, there were no differences in outcomes among institutions.

CONCLUSIONS

This study suggests that despite the challenges faced at safety net hospitals, it could be feasible to safely perform minimally invasive foregut surgery with similar outcomes to private and university hospitals.

Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery

PURPOSE

Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits.

METHODS

All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery.

RESULTS

Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors.

CONCLUSIONS

Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Weekend Versus Weekday Asthma-Related Emergency Department Utilization

OBJECTIVE

To assess variation in asthma-related emergency department (ED) use between weekends and weekdays.

METHODS

Cross-sectional administrative claims-based analysis using California 2016 Medicaid data and Vermont 2016 and Massachusetts 2015 all-payer claims databases. We defined ED use as the rate of asthma-related ED visits per 100 child-years. A weekend visit was a visit on Saturday or Sunday, based on date of ED visit claim. We used negative binomial regression and robust standard errors to assess variation between weekend and weekday rates, overall and by age group.

RESULTS

We evaluated data from 398,537 patients with asthma. The asthma-related ED visit rate was slightly lower on weekends (weekend: 18.7 [95% confidence interval (CI): 18.3-19.0], weekday: 19.6 [95% CI, 19.3-19.8], P < .001). When stratifying by age group, 3- to 5-year-olds had higher rates of asthma-related ED visits on weekends than weekdays (weekend: 33.7 [95% CI, 32.6-34.7], weekday: 29.8 [95% CI, 29.1-30.5], P < .001) and 12- to 17-year-olds had lower rates of ED visits on weekends than weekdays (weekend: 13.0 [95% CI: 12.5-13.4], weekday: 16.3 [95% CI: 15.9-16.7], P < .001). In the other age groups (6-11, 18-21 years) there were not statistically significant differences between weekend and weekday rates (P > .05).

CONCLUSIONS

In this multistate analysis of children with asthma, we found limited overall variation in pediatric asthma-related ED utilization on weekends versus weekdays. These findings suggest that increasing access options during the weekend may not necessarily decrease asthma-related ED use.

Dizziness Diagnostic Pathways: Factors Impacting Setting, Provider, and Diagnosis at Presentation

OBJECTIVE

Ensuring that patients with dizziness present to the most appropriate level of care and provider are key goals of quality and cost improvement efforts. Using a symptom-defined cohort of adults presenting for dizziness evaluations, we aimed to identify patient factors associated with ambulatory clinic vs emergency department (ED) presentations, evaluating provider specialty, and assigned diagnoses.

STUDY DESIGN

Cross-sectional study.

SETTING

OptumLabs Data Warehouse (OLDW), a longitudinal, real-world data asset with deidentified administrative claims.

METHODS

We performed a cross-sectional analysis of adults (older than 18 years) who received new dizziness diagnoses (2006-2015) and identified factors associated with setting and provider at initial presentation using multivariable regression models.

RESULTS

Of 805,454 individuals with dizziness (median age 52 years, 62% women, 29% black, Asian, or Hispanic), 23% presented to EDs and 77% to clinics (76% primary care, 7% otolaryngology, 5% cardiology, 3% neurology). Predictors of ED presentation were younger age, male sex, black race, lower education, and medical comorbidity. Predictors of primary care clinic presentation were older age and race/ethnicity other than white. Nonetiologic symptom diagnoses alone were assigned to 51% and were most associated with age older than 75 years (odds ratio, 2.90; 95% CI, 2.86-2.94).

CONCLUSION

Adults with dizziness often present to a level of care that may be higher than is optimal. Differential care seeking and diagnoses by age, sex, and race/ethnicity reflect influences beyond dizziness presentation acuity. Targeted patient resources, triage systems, provider education, and cross-specialty partnerships are needed to direct dizzy patients to appropriate settings and providers to improve care.

Ambulatory care, insurance, and avoidable emergency department utilization in North Carolina

OBJECTIVE

To examine whether and how avoidable emergency department (ED) utilization is associated with ambulatory or primary care (APC) utilization, insurance, and interaction effects.

DESIGN AND SAMPLE

A cross-sectional analysis of electronic health records from 70,870 adults residing in Mecklenburg County, North Carolina, who visited an ED within a large integrated healthcare system in 2017.

METHODS

APC utilization was measured as total visits, categorized as: 0, 1, and > 1. Insurance was defined as the method of payment for the ED visit as: Medicaid, Medicare, private, or uninsured. Avoidable ED utilization was quantified as a score (aED), calculated as the sum of New York University Algorithm probabilities multiplied by 100. Quantile regression models were used to predict the 25th, 50th, 75th, 95th, and 99th percentiles of avoidable ED scores with APC visits and insurance as predictors (Model 1) and with an interaction term (Model 2).

RESULTS

Having >1 APC visit was negatively associated with aED at the lower percentiles and positively associated at higher percentiles. A higher aED was associated with having Medicaid insurance and a lower aED was associated with having private insurance, compared to being uninsured. In stratified models, having >1 APC visit was negatively associated with aED at the 25th percentile for the uninsured and privately insured, but positively associated with aED at higher percentiles among the uninsured, Medicaid-insured, and privately insured.

CONCLUSIONS

The association between APC utilization and avoidable ED utilization varied based on segments of the distribution of ED score and differed significantly by insurance type.

Primary Care Access to New Patient Appointments for California Medicaid Enrollees: A Simulated Patient Study

PURPOSE

We undertook a study to evaluate variation in the availability of primary care new patient appointments for Medi-Cal (California Medicaid) enrollees in Northern California, and its relationship to emergency department (ED) use after Medicaid expansion.

METHODS

We placed simulated calls by purported Medi-Cal enrollees to 581 primary care clinicians (PCCs) listed as accepting new patients in online directories of Medi-Cal managed care plans. Data from the California Health Interview Survey, Medi-Cal enrollment reports, and California hospital discharge records were used in analyses. We developed multilevel, mixed-effect models to evaluate variation in appointment access. Multiple linear regression was used to examine the relationship between primary care access and ED use by county.

RESULTS

Availability of PCC new patient appointments to Medi-Cal enrollees lacking a PCC varied significantly across counties in the multilevel model, ranging from 77 enrollees (95% CI, 70-81) to 472 enrollees (95% CI, 378-628) per each available new patient appointment. Just 19% of PCCs had available appointments within the state-mandated 10 business days. Clinicians at Federally Qualified Health Centers had higher availability of new patient appointments (rate ratio = 1.56; 95% CI, 1.24-1.97). Counties with poorer PCC access had higher ED use by Medi-Cal enrollees.

CONCLUSIONS

In contrast to findings from other states, access to primary care in Northern California was limited for new patient Medi-Cal enrollees and varied across counties, despite standard statewide reimbursement rates. Counties with more limited access to primary care new patient appointments had higher ED use by Medi-Cal enrollees.

Recent Trends and the Impact of the Affordable Care Act on Emergency Department Visits and Hospitalizations for Gastrointestinal, Pancreatic, and Liver Diseases

BACKGROUND

The Affordable Care Act (ACA) with Medicaid expansion implemented in 2014, extended health insurance to >20-million previously uninsured individuals. However, it is unclear whether enhanced primary care access with Medicaid expansion decreased emergency department (ED) visits and hospitalizations for gastrointestinal (GI)/pancreatic/liver diseases.

METHODS

We evaluated trends in GI/pancreatic/liver diagnosis-specific ED/hospital utilization over a 5-year period leading up to Medicaid expansion and a year following expansion, in California (a state that implemented Medicaid expansion) and compare these with Florida (a state that did not).

RESULTS

From 2009 to 2013, GI/pancreatic/liver disease ED visits increased by 15.0% in California and 20.2% in Florida and hospitalizations for these conditions decreased by 2.6% in California and increased by 7.9% in Florida. Following Medicaid expansion, a shift from self-pay/uninsured to Medicaid insurance was seen California; in addition, a new decrease in ED visits for nausea/vomiting and GI infections, was evident, without associated change in overall ED/hospital utilization trends. Total hospitalization charges for abdominal pain, nausea/vomiting, constipation, and GI infection diagnoses decreased in California following Medicaid expansion, but increased over the same time-period in Florida.

CONCLUSIONS

We observed a striking payer shift for GI/pancreatic/liver disease ED visits/hospitalizations after Medicaid expansion in California, indicating a shift in the reimbursement burden in self-pay/uninsured patients, from patients and hospitals to the government. ED visits and hospitalization charges decreased for some primary care-treatable GI diagnoses in California, but not for Florida, suggesting a trend toward lower cost of gastroenterology care, perhaps because of decreased hospital utilization for conditions amenable to outpatient management.

Back so soon? Characterizing emergency department use after trauma

BACKGROUND

Trauma readmissions have been well studied but little data exists regarding Emergency Department (ED) utilization following an injury. This study was performed to determine the factors associated with a return to the ED after trauma.

METHODS

A retrospective review of all adult trauma patients evaluated between January and December of 2014 was performed. Demographics, follow-up plan, and characteristics of ED visits within 30 days of discharge were recorded. Predictive factors of ED utilization were identified using univariate analysis and multi-logistic regression.

RESULTS

Fourteen percent of 1836 consecutive patients returned to the ED within 30 days of initial trauma. On multi-logistic regression, penetrating trauma (OR 2.15 p = 0.001), and scheduled follow-up (OR 1.81 p = 0.046) remained significant predictors.

CONCLUSIONS

Penetrating trauma victims are at increased risk of returning to the ED, most often because of wound or pain issues. Recognizing these factors allows for targeted interventions to decrease ED resource utilization.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BACKGROUND

Inappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding. The aim of this study was to explore socioeconomic and geographical determinants of inappropriate ED use in France.

METHOD

The French Emergency Survey was a nationwide cross-sectional survey conducted on June 11 2013, simultaneously in all EDs in France and covered characteristics of patients, EDs and counties. The survey included 48 711 patient questionnaires and 734 ED questionnaires. We focused on adult patients (≥15 years old). The appropriateness of the ED visit was assessed by three measures: caring physician appreciation of appropriateness (numeric scale), caring physician appreciation of whether or not the patient could have been managed by a general practitioner and ED resource utilisation. Descriptive statistics and multilevel logistic regression were used to examine determinants of inappropriate ED use, estimating adjusted ORs and 95% CIs.

RESULTS

Among the 29 407 patients in our sample, depending on the measuring method, 13.5% to 27.4% ED visits were considered inappropriate. Regardless of the measure method used, likelihood of inappropriate use decreased with older age and distance from home to the ED >10 km. Not having a private supplementary health insurance, having universal supplementary health coverage and symptoms being several days old increased the likelihood of inappropriate use. Likelihood of inappropriate use was not associated with county medical density.

CONCLUSION

Inappropriate ED use appeared associated with socioeconomic vulnerability (such as not having supplementary health coverage or having universal coverage) but not with geographical characteristics. It makes us question the appropriateness of the concept of inappropriate ED use as it does not consider the distress experienced by the patient, and segments of society seem to have few other choices to access healthcare than the ED.

Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study

Background

It is critical to understand whether providing health insurance coverage, assigning a dedicated Primary Care Physician (PCP), and arranging timely post-Emergency Department (ED) clinic follow-up can improve compliance with clinic visits and reduce ED discharge failures. We aim to determine the benefits of providing these common step-wise interventions and further investigate the necessity of urgent PCP referrals on behalf of ED discharged patients.

Methods

This is a single-center retrospective observational study. All patients discharged from the ED over the period Jan 1, 2015 through Dec 31, 2017 were included in the study population. Step-wise interventions included providing charity health insurance, assigning a dedicated PCP, and providing ED follow-up clinics. PCP clinic compliance and ED discharge failures were measured and compared among groups receiving different interventions.

Result

A total of 227,627 patients were included. Fifty-eight percent of patients receiving charity insurance had PCP visits in comparison to 23% of patients without charity insurance (p < 0.001). Seventy-seven percent of patients with charity insurance and PCP assignments completed post-ED discharge PCP visits in comparison to only 4.5% of those with neither charity insurance nor PCP assignments (p < 0.001).

Conclusions

Step-wise interventions increased patient clinic follow-up compliance while simultaneously reducing ED discharge failures. Such interventions might benefit communities with similar patient populations.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4300-1) contains supplementary material, which is available to authorized users.

Patient Uncertainty as a Predictor of 30-day Return Emergency Department Visits: An Observational Study

OBJECTIVE

The objective was to examine the relationship between patient uncertainty at the time of emergency department (ED) discharge as measured by the "Uncertainty Scale" (U-Scale) and 30-day return ED visits. We hypothesized that a higher score on the U-Scale predicts a higher likelihood of a 30-day return ED visit.

METHODS

This was a cross-sectional single-site pilot study performed with adult patients discharged from an urban academic ED to assess the relationship of U-Scale total and subscale scores with 30-day return ED visits. We collected demographic and U-Scale scores at the time of ED discharge and subsequent 30-day ED utilization data by follow-up telephone call.

RESULTS

No association was found between the total U-Scale score and subsequent ED utilization. Patients with higher uncertainty on the Treatment Quality subscale of the U-Scale had higher odds of a 30-day return ED visit (adjusted odds ratio [AOR] = 1.16), while patients with lower uncertainty on the Decision to Seek Care subscale had higher odds of a 30-day return ED visit (AOR = 0.68).

CONCLUSION

Patient uncertainty as measured by the U-Scale total score was not predictive of subsequent ED utilization. However, uncertainty related to treatment quality and the decision to seek care as measured by the U-Scale subscales may be important in predicting repeat ED utilization. Unlike individual patient factors such as age and race that have been associated with frequent ED visits in prior studies, these domains of uncertainty are potentially modifiable. Providers and health systems may successfully prevent recurrent acute care encounters through implementation of interventions designed to address patient uncertainty. Further work is needed to refine the U-Scale and test its predictive utility among a larger patient cohort.

General practitioner consultation after a visit to the emergency department: an observational study

BACKGROUND

Some studies have demonstrated an association between poor continuity of care, high likelihood of 'inappropriate' use of emergency departments (EDs) and avoidable hospitalization. However, we lack data concerning primary care use after an ED visit.

OBJECTIVE

Identify the determinants of a visit to the general practitioner (GP) after an ED visit.Methods.

DESIGN

Observational study (single-centre cohort).

SETTING

One emergency department in Paris, France.

SUBJECTS

All adult patients who presented at the ED and were discharged.

MAIN OUTCOME MEASURE

We collected data by the use of a standardized questionnaire, patients' medical records and a telephonic follow-up. Descriptive analyses were performed to compare individuals with and without a GP. Then, for those with a GP, multivariate logistic regression was used to identify the determinants of the GP consultation.

RESULTS

We included 243 patients (mean age 45 years [±19]); 211 (87%) reported having a GP. Among those who reported having a GP, 52% had consulted their GP after the ED visit. Not having a GP was associated with young age, not having complementary health insurance coverage, and being single. GP consultation was associated with increasing age [adjusted odds ratios (aOR) = 1.03], poor self-reported health status (aOR = 2.25), medical complaints versus traumatic injuries (aOR = 2.24) and prescription for sick note (aOR = 5.74).

CONCLUSION

Not having a GP was associated with factors of social vulnerability such as not having complementary health insurance coverage. For patients with a GP, consultation in the month after an ED visit seems appropriate, because it was associated with poor health status and medical complaints.

Predictors for Surgery-Related Emergency Department Visits within 30 Days of Foot and Ankle Surgeries

Presentation to an emergency department (ED) after foot and ankle surgeries not only causes inconvenience to patients but also increases healthcare costs. To minimize this, many major institutions have tracked these data as a part of quality improvement measures. Our previous study showed that factors associated with any (surgery-related and unrelated) postoperative ED visits were not easily modifiable by surgeons. Therefore, in the current study, we focused on factors associated specifically with surgery-related postoperative ED visits, because this may provide some insights for surgeons rather than just administrators. We examined 513 foot and ankle surgeries, of which 114 resulted in 30-day postoperative ED visits for surgery-related reasons. Demographic, medical, and surgical factors were evaluated, and risk factors were identified after adjusting for potential clinically relevant covariates. Both inpatient and outpatient surgical settings and outpatient surgical settings alone were analyzed separately. Regardless of the setting, we found that shorter surgery was protective against postoperative ED visits, as was having a previous ED visit within 6 months before surgery. In the outpatient setting, younger age and having no insurance were also proxies for a postoperative ED visit, in addition to the above factors.

Access to Federally Qualified Health Centers and Emergency Department Use Among Uninsured and Medicaid-insured Adults: California, 2005 to 2013

BACKGROUND

While improved access to safety net primary care providers, like federally qualified health centers (FQHCs), is often cited as a route to alleviate potentially preventable emergency department (ED) visits, no studies have longitudinally established the impact of improving access to FQHCs on ED use among Medicaid-insured and uninsured adults. We aimed to determine whether improved access to FQHCs was associated with lower ED use by uninsured and Medicaid-insured adults.

METHODS

Using data from the Uniform Data System, U.S. Census Bureau, and California Office of Statewide Health Planning & Development, we conducted a longitudinal analysis of 58 California counties from 2005 to 2013. For each county-year observation, we employed three measures of FQHC access: geographic density of FQHCs (delivery sites per 100 square miles), FQHCs per county resident (delivery sites per 100,000 county residents), and the proportion of Medicaid-insured or uninsured residents ages 19 to 64 years that utilized FQHCs. We then used a fixed-effects model to examine the impact of changes in the measures of FQHC access on ED visit rates by Medicaid-insured or uninsured adults in each county.

RESULTS

Increasing geographic density of FQHCs was associated with a 26% to 35% decrease in ED use by uninsured but not Medicaid-insured patients. Increasing numbers of clinics per county resident and higher percentages of Medicaid-insured and uninsured adults seen at FQHCs were not associated with reduced rates of ED use among either uninsured or Medicaid-insured adults.

CONCLUSIONS

We were unable to detect a consistent association between our measures of FQHC access and ED use by Medicaid-insured and uninsured nonelderly California adults, underscoring the importance of investigating additional drivers to reduce ED use among these vulnerable patient populations.

Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events

BACKGROUND AND OBJECTIVES

Little is known about opioid prescribing for children without severe conditions. We studied the prevalence of and indications for outpatient opioid prescriptions and the incidence of opioid-related adverse events in this population.

METHODS

This retrospective cohort study between 1999 and 2014 included Tennessee Medicaid children and adolescents aged 2 to 17 without major chronic diseases, prolonged hospitalization, institutional residence, or evidence of a substance use disorder. We estimated the annual prevalence of outpatient opioid prescriptions and incidence of opioid-related adverse events, defined as an emergency department visit, hospitalization, or death related to an opioid adverse effect.

RESULTS

There were 1 362 503 outpatient opioid prescriptions; the annual mean prevalence of opioid prescriptions was 15.0%. The most common opioid indications were dental procedures (31.1% prescriptions), outpatient procedure and/or surgery (25.1%), trauma (18.1%), and infections (16.5%). There were 437 cases of opioid-related adverse events confirmed by medical record review; 88.6% were related to the child's prescription and 71.2% had no recorded evidence of deviation from the prescribed regimen. The cumulative incidence of opioid-related adverse events was 38.3 of 100 000 prescriptions. Adverse events increased with age (incidence rate ratio = 2.22; 95% confidence interval, 1.67-2.96; 12-17 vs 2-5 years of age) and higher opioid doses (incidence rate ratio = 1.86 [1.45-2.39]; upper versus lower dose tertiles).

CONCLUSIONS

Children without severe conditions enrolled in Tennessee Medicaid frequently filled outpatient opioid prescriptions for acute, self-limited conditions. One of every 2611 study opioid prescriptions was followed by an opioid-related adverse event (71.2% of which were related to therapeutic use of the prescribed opioid).

The French Emergency National Survey: A description of emergency departments and patients in France

INTRODUCTION

Some major changes have occurred in emergency department (ED) organization since the early 2000s, such as the establishment of triage nurses and short-track systems. The objectives of this study were to describe the characteristics of French EDs organization and users, based on a nationwide cross-sectional survey.

METHODS

The French Emergency Survey was a nationwide cross-sectional survey. All patients presenting to all EDs during a 24-hr period of June 2013 were included. Data collection concerned ED characteristics as well as patient characteristics.

RESULTS

Among the 736 EDs in France, 734 were surveyed. Triage nurses and short-track systems were respectively implemented in 73% and 41% of general EDs. The median proportion of patients aged > 75 years was 14% and median hospitalisation rate was 20%. During the study period, 48,711 patients presented to one of the 734 EDs surveyed. Among them, 7% reported having no supplementary health or universal coverage (for people with lower incomes). Overall, 50% of adult patients had been seen by the triage nurse in less than 5 minutes, 74% had a time to first medical contact shorter than one hour and 55% had an ED length of stay shorter than 3 hours.

CONCLUSION

The French Emergency Survey is the first study to provide data on almost all EDs in France. It underlines how ED organization has been redesigned to face the increase in the annual census. French EDs appear to have a particular role for vulnerable people: age-related vulnerability and socio-economic vulnerability with an over-representation of patients without complementary health coverage.

Factors associated with emergency room visits within 30 days of outpatient foot and ankle surgeries

The number of emergency department (ED) visits within 30 days after elective surgery has been utilized as a quality measure by many institutions. The significance of the measure as a postoperative complication in foot and ankle surgery, and risk factors for it, are unknown. We conducted a retrospective cohort study involving 386 patients to determine risk factors associated with ED visits after outpatient foot and ankle surgeries. After adjusting for clinically relevant covariates, we found that previous ED visits within 6 months of surgery, and nonelective surgeries were associated with the postoperative ED visit. Having private insurance was protective against postoperative ED visits. Though these risk factors may not be easily modifiable by surgeons, understanding them may improve patient education and transitional care to prevent overcrowding of the ED.

Medicaid Managed Care in Florida and Racial and Ethnic Disparities in Preventable Emergency Department Visits

BACKGROUND

In an effort to address health care spending growth, coordinate care, and improve access to primary care in the Medicaid program, Florida implemented the Statewide Mandatory Managed Care (SMMC) program in May of 2014.

OBJECTIVES

The objective of this study is to investigate the impact of implementation of mandatory managed care in Medicaid on the preventable emergency department (ED) utilizations, with a focus on racial/ethnic minorities.

RESEARCH DESIGN

The primary data source is the universe of Florida ED visit and inpatient discharge data from 2010 to 2015, maintained by the Florida Agency for Health Care Administration. We adopt the New York University Billing's ED Classification Algorithm to create measures for preventable ED visits. Using difference-in-differences estimation, we examine preventable ED visits for Florida residents aged 18-64 with a primary payer of Medicaid (treatment group) and private health insurance (control group) pre-SMMC and post-SMMC reform.

RESULTS

Our findings show that SMMC is statistically significantly associated with more reductions in preventable ED visits among non-Hispanic African American (incidence rate ratio=0.81; 95% confidence interval, 0.70-0.94) and Hispanic (incidence rate ratio=0.72; 95% CI, 0.60-0.87) Medicaid enrollees relative to their white counterparts. We also find significant reduction of racial/ethnic disparities only in counties with above median preimplementation Medicaid managed care penetration rate.

CONCLUSIONS

Our findings suggest that implementation of Medicaid mandatory managed care in Florida is associated with reduced racial/ethnic disparities in preventable ED visits.

Health Care Service Use Among Elderly Seasonal Migrators

Elderly seasonal migrators share time between homes in different states, presenting challenges for care coordination and patient attribution methods. Medicare has prioritized alternative payment models, putting health care providers at risk for quality and value of services delivered to their attributed patients, regardless of the location of care. Little research is available to guide providers and payers on the service use of seasonal migrators. The authors use claims data on fee-for-service (FFS) Medicare beneficiaries' locations throughout the year to (1) identify seasonal migrators and (2) describe the care they receive in each seasonal home, focusing on primary care and emergency department (ED) visits and the relationships between the two. In all, 5.5% of the Medicare aged FFS population were identified as seasonal migrators, with 4.1% following the traditional snowbird pattern of migration, spending warm months in the north and cold months in the south. Migrators had higher rates of ED visits and primary care treatable (PCT) ED visits than the nonmigratory groups, controlling for location, age, race, sex, Medicaid status, season, and comorbidities. They also had more visits with specialist physicians, more days with outpatient services, and more days seeing a physician in any setting. Having local primary care strongly reduced rates of both PCT ED visits and total ED visits for all migration categories, with the greatest reduction seen in PCT ED visits by migrators (local primary care was associated with a 58% reduction in PCT ED visits by snowbirds and a 65% reduction in PCT ED visits by other migrators).

Medicaid Expansion In 2014 Did Not Increase Emergency Department Use But Did Change Insurance Payer Mix

In 2014 twenty-eight states and the District of Columbia had expanded Medicaid eligibility while federal and state-based Marketplaces in every state made subsidized private health insurance available to qualified individuals. As a result, about seventeen million previously uninsured Americans gained health insurance in 2014. Many policy makers had predicted that Medicaid expansion would lead to greatly increased use of hospital emergency departments (EDs). We examined the effect of insurance expansion on ED use in 478 hospitals in 36 states during the first year of expansion (2014). In difference-in-differences analyses, Medicaid expansion increased Medicaid-paid ED visits in those states by 27.1 percent, decreased uninsured visits by 31.4 percent, and decreased privately insured visits by 6.7 percent during the first year of expansion compared to nonexpansion states. Overall, however, total ED visits grew by less than 3 percent in 2014 compared to 2012-13, with no significant difference between expansion and nonexpansion states. Thus, the expansion of Medicaid coverage strongly affected payer mix but did not significantly affect overall ED use, even though more people gained insurance coverage in expansion states than in nonexpansion states. This suggests that expanding Medicaid did not significantly increase or decrease overall ED visit volume.

Epidemiological characteristics of pediatric epistaxis presenting to the emergency department

OBJECTIVE

Investigate the epidemiological characteristics of pediatric epistaxis in the emergency department setting.

STUDY DESIGN

Cross-sectional study using national databases.

METHODS

Children (age <18 years) presenting with a diagnosis of epistaxis were extracted from the State Emergency Department Databases for New York, Florida, Iowa, and California for the calendar year 2010. Associated diagnoses, procedures, encounter characteristics, and demographic data were examined.

RESULTS

There were 18,745 cases of pediatric epistaxis (mean age 7.54 years, 57.4% male). Overall, 6.9% of patients underwent procedures to control epistaxis, of which 93.5% had simple anterior epistaxis control. The distribution of pediatric epistaxis was highest in spring and summer months (p < 0.001). Children from the lowest income quartile comprised a higher proportion of epistaxis presentations (38.8%, p < 0.001), yet were least likely to have an epistaxis control procedure performed (p < 0.001). Most patients had either Medicaid (43.8%) or private insurance (41.3%). Patients with Medicaid and those without healthcare coverage were least likely to undergo an epistaxis control procedure (p < 0.001). White children were more likely to undergo an epistaxis control procedure compared to those of minority backgrounds (p < 0.001).

CONCLUSIONS

Most emergency department presentations of pediatric epistaxis are uninvolved cases that do not require procedural intervention. The overrepresentation of low socioeconomic status patients may suggest an overutilization of emergency services for minor cases of epistaxis, and perhaps a lack of access to primary care providers. This is the first study to evaluate racial and socioeconomic factors in relationship to pediatric epistaxis. Further investigation is needed to better elucidate these potential disparities.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois

Introduction

This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012–2013) pre-ACA period and a 24-month post-ACA (2014–2015) period across 88 socioeconomically diverse areas of Illinois.

Methods

We used annual American Community Survey estimates for 2012–2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18–64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.

Results

The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012–2013, 2014–2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.

Conclusion

ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Federally Qualified Health Center Access and Emergency Department Use Among Children

OBJECTIVE

To determine whether increasing access to federally qualified health centers (FQHCs) in California was associated with decreased rates of emergency department (ED) use by children without insurance or insured by Medicaid.

METHODS

We combined several data sets to longitudinally analyze 58 California counties between 2005 and 2013. We defined access to FQHCs by county using 2 measures: FQHC sites per 100 square miles between 2005 and 2012 and percentage of Medicaid-insured and uninsured children served by FQHCs from 2008 to 2013. Our outcome was rates of ED use by uninsured or Medicaid-insured children ages 0 to 18 years. To determine the effect of changes in FQHC access on the outcome within a county over time, we used negative binomial models with county fixed effects and controls for preselected time-varying county characteristics and secular trends.

RESULTS

Increased geographic density of FQHC sites was associated with ≤18% lower rates of ED visits among Medicaid-insured children and ≤40% lower ED utilization among uninsured children (P = .05 and P < .01, respectively). However, the percentage of Medicaid-insured and uninsured children seen at FQHCs was not associated with any significant change in ED visit rates among Medicaid-insured or uninsured children.

CONCLUSIONS

Whereas increased geographic FQHC access was associated with lower rates of ED use by uninsured children, all other measures of FQHC access were not associated with statistically significant changes in pediatric ED use. These results provide community-level evidence that expanding FQHCs may have a limited impact on pediatric ED use, suggesting the need to explore additional factors driving ED utilization.

Site of Treatment for Non-Urgent Conditions by Medicare Beneficiaries: Is There a Role for Urgent Care Centers?

BACKGROUND

There is limited information on where and how often Medicare beneficiaries seek care for non-urgent conditions when a physician office visit is not available. Emergency departments are often an alternative site of care, and urgent care centers have now also emerged to fill this need. The purpose of the study was to characterize the site of care for Medicare beneficiaries with non-urgent conditions; the relationship between physician office, urgent care center, and emergency department utilization; and specifically the role of urgent care centers.

METHODS

The study is a retrospective, cross-sectional study of fee-for-service Medicare beneficiaries for fiscal year 2012. The main outcome was rate and geographic variation of urgent care center, emergency department, or physician office utilization.

RESULTS

Care for non-urgent conditions most commonly occurred in physician offices (65.0 per 100 beneficiaries). In contrast, urgent care centers (6.0 per 100 beneficiaries) were a more common site of care than emergency departments (1.0 per 100 beneficiaries). Overall, 83% of non-urgent visits were physician offices, 14% urgent care centers, and 3% emergency departments. There was regional variation in urgent care center, emergency department, and physician office utilization for non-urgent conditions. Areas of higher emergency department utilization correspond to areas of lower urgent care center and physician office utilization, whereas areas of higher urgent care center utilization had lower emergency department utilization.

CONCLUSIONS

Urgent care centers are an important site of care for Medicare beneficiaries for non-urgent conditions. There is regional variation in the use of urgent care centers, emergency departments, and physician offices, with areas of low urgent care center utilization having higher emergency department utilization. The utilization of urgent care centers for treatment for non-urgent conditions may decrease emergency department utilization.

Retrospective one-million-subject fixed-cohort survey of utilization of emergency departments due to traumatic causes in Taiwan, 2001-2010

BACKGROUND

Epidemiological study was needed to evaluate trends in emergency department (ED) utilization that could be taken into account when making policy decisions regarding the delivery and distribution of medical resources.

METHODS

A retrospective fixed-cohort study of emergency medical utilization from 2001 to 2010 was performed based on one-million people sampled in 2010 in Taiwan. Focusing on traumatic cases, the annual incidences in various groups split according to sex and age were calculated, and further information regarding location of trauma and type of trauma was obtained.

RESULTS

In 2010, significantly greater proportions of male and younger subjects were visitors to EDs with a traumatic injury. During 2001-2010, the number of both traumatic cases and non-traumatic cases presenting at EDs significantly increased (average annual percentage change, AAPC 4.7 and 3.6, respectively) and a significantly greater direct medical cost associated with traumatic cases than non-traumatic cases was noted. Focusing on traumatic cases, most of these cases were directed to highest-level hospitals, accounting for 73.5-78.8 % of all traumatic cases, with a significant AAPC of 5.6. The traumatic ED visit annual incidence in males was 58.63 in 2001, which significantly increased to 69.35 per 1000 persons in 2010 (AAPC 1.5); and in females was 38.96 in 2001, which significantly increased to 50.73 per 1000 persons in 2010 (AAPC 2.5). Most of the traumatic cases treated in EDs were minor injuries, such as contusion with the skin intact, open wound of the upper limbs, open wound of the head, neck, or trunk, and other superficial injury (accounting for about 60 % of all cases). The traumatic categories of sprains/strains of joints and adjacent muscles, fractures of upper limbs, fractures of lower limbs, and fractures of the spine/trunk required greater medical resources and significantly positive AAPC values (4.3, 4.0, 4.5 and 6.8, respectively).

CONCLUSIONS

Increased ED utilization due to traumatic causes, as assessed by the annual number of cases and incidence, average direct medical cost and highest-level hospital utilization, was observed from 2001 to 2010. Orthopedic-related injuries, including soft tissue trauma of extremities and various fractures, were the categories with the greatest increase in incidence.

Presentation to Emergency Departments for Acute Rhinosinusitis

Objective

Medicaid and self-pay insurance statuses and race are associated with emergency department (ED) presentation for uncomplicated acute rhinosinusitis (ARS). We investigated whether ARS symptomatology could explain this disproportionate ED use.

Study Design

2006-2010 National Hospital Ambulatory Medical Care Surveys.

Setting

EDs in the United States.

Subjects and Methods

The data comprise 1,632,826 adult visits for uncomplicated ARS at hospital EDs. Patient-reported reasons for presentation included constitutional symptoms, facial pain or headache, sinonasal symptoms, head cold or flu-like symptoms, cough or sputum production, and sore throat. Patient-reported pain level was also included. Symptoms were assessed for associations with insurance status and race after controlling for clinical, demographic, and socioeconomic characteristics.

Results

Medicaid patients had similar symptomatology and levels of pain when compared with privately insured patients. Self-pay patients reported higher pain levels ( P = .033) and were less likely to report head cold or flu-like symptoms ( P = .018) but were equally likely to report other symptomatology. Relative to white patients, Hispanic patients were more likely to complain of facial pain and headaches ( P = .033) and less likely to complain of other classical ARS symptoms, such as cough or sputum production ( P = .013), sinonasal symptoms ( P = .019), or head cold or flu-like symptoms ( P = .019). Black patients were also less likely to complain of sinonasal symptoms ( P = .038).

Conclusion

Symptomatology does not explain disproportionate ED use for ARS by Medicaid patients, while higher self-reported pain levels may explain self-pay patients’ disproportionate ED utilization. Likewise, ED presentation for ARS among Hispanic patients may be related to symptomatology that is less specific for ARS, such as headache and facial pain.

Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive condition conditions

INTRODUCTION

Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States.

METHODS

We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC.

RESULTS

There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured.

CONCLUSION

Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.

Use of Physical Therapy for Low Back Pain by Medicaid Enrollees

BACKGROUND

Medicaid insures an increasing proportion of adults in the United States. Physical therapy use for low back pain (LBP) in this population has not been described.

OBJECTIVE

The study objectives were: (1) to examine physical therapy use by Medicaid enrollees with new LBP consultations and (2) to evaluate associations with future health care use and LBP-related costs.

DESIGN

The study was designed as a retrospective evaluation of claims data.

METHODS

A total of 2,289 patients with new LBP consultations were identified during 2012 (mean age=39.3 years [SD=11.9]; 68.2% women). The settings in which the patients entered care and comorbid conditions were identified. Data obtained at 1 year after entry were examined, and physical therapy use was categorized with regard to entry setting, early use (within 14 days of entry), or delayed use (>14 days after entry). The 1-year follow-up period was evaluated for use outcomes (imaging, injection, surgery, and emergency department visit) and LBP-related costs. Variables associated with physical therapy use and cost outcomes were evaluated with multivariate models.

RESULTS

Physical therapy was used by 457 patients (20.0%); 75 (3.3%) entered care in physical therapy, 89 (3.9%) received early physical therapy, and 298 (13.0%) received delayed physical therapy. Physical therapy was more common with chronic pain or obesity comorbidities and less likely with substance use disorders. Entering care in the emergency department decreased the likelihood of physical therapy. Entering care in physical medicine increased the likelihood. Relative to primary care entry, physical therapy entry was associated with lower 1-year costs.

LIMITATIONS

A single state was studied. No patient-reported outcomes were included.

CONCLUSIONS

Physical therapy was used often by Medicaid enrollees with LBP. High rates of comorbidities were evident and associated with physical therapy use. Although few patients entered care in physical therapy, this pattern may be useful for managing costs.

Access to care issues and the role of EDs in the wake of the Affordable Care Act

CONTEXT

Americans who received public insurance under the Affordable Care Act use the emergency department (ED) more frequently than before they were insured. If newly enrolled patients cannot access primary care and instead rely on the ED, they may not enjoy the full benefits of health care services.

OBJECTIVE

The objective of the study is to characterize reasons for ED utilization among American adults by insurance status and usual source of care.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis of adult sample respondents to the 2013 National Health Interview Survey reporting 1 or more ED visits in the preceding 12 months.

MAIN OUTCOMES AND MEASURES

Among American ED users that reported no usual source of care and who reported relying on the ED, 27.7% (95% confidence interval [CI], 23.6%-32.2%) and 35.1% (95% CI, 28.0%-43.0%) noted at least 1 issue of access and none of acuity as a reason for their last ED visit, as compared to 17.7% (95% CI, 16.3%-19.2%) among those with a stable usual source of care.

CONCLUSIONS AND RELEVANCE

Although past research has shown that those who lack a stable usual source of care use the ED more often, this is the first population-level study to demonstrate their propensity for lack of access-based utilization. In the wake of the Affordable Care Act, EDs will need to evolve into outlets that service a wider range of health care needs rather than function in their current capacity, which is largely to address acute issues in isolation.