Chartbook on Care Coordination

• Emergency department (ED) visits are costly.
• Because some visits are preventable, they may indicate poor care management, inadequate access to care, or poor choices on the part of patients (Dowd, et al., 2014).
• ED visits for conditions that are preventable or treatable with appropriate primary care lower health system efficiency and raise costs (Enard & Ganelin, 2013).
• An estimated 13% to 27% of ED visits in the United States could be managed in physician offices, clinics, and urgent care centers, saving $4.4 billion annually (Weinick, et al., 2010).

Measures of preventable ED visits include:

• ED visits with a principal diagnosis related to mental health, alcohol, or substance abuse.
• ED visits with a principal diagnosis of dental conditions.
• ED visits for asthma, ages 18-39.
• ED visits for asthma, ages 2-17.

Emergency Department Visits Related to Mental Health, Alcohol, or Substance Abuse

Emergency department visits with a principal diagnosis related to mental health, alcohol, or substance abuse, by age and income, 2007-2013

Left Chart:

Right Chart:

Key: Q = quartile of median household income of the patient's ZIP code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, and HCUPnet query, 2007-2013.

• Importance: Frequent ED users with mental health and addiction challenges are in dire need of effective treatment and case management. Further, pediatric emergency physicians may struggle to provide effective care and consider the ED ill suited to ensure continuity of care when treating alcohol-related issues among adolescents.
• Trends:
  • From 2007 to 2013, the overall rate of ED visits with a principal diagnosis related to mental health, alcohol, or substance abuse increased from 1,527.8 to 1,883.0 per 100,000 population.
  • From 2007 to 2013, the rate of ED visits with a principal diagnosis related to mental health, alcohol, or substance abuse increased among all age and income groups.
• Groups With Disparities:
  • In all years, individuals in the highest income quartile were less likely than individuals in all other income groups to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse.
  • In all years, individuals ages 0-17 and 65 and over were significantly less likely than individuals ages 18-44 to have an ED visit with a principal diagnosis related to mental health, alcohol, or substance abuse.

Emergency Department Visits Related to Mental Health Only

Emergency department visits with a principal diagnosis related to mental health only, by region and income, 2007-2013

Left Chart:

Right Chart:

Key: Q = quartile of median household income of the patient's ZIP code of residence
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, and HCUPnet query, 2007-2013.

• Importance: Adults with mental health disorders are less likely to care for their chronic medical conditions and have worse outcomes of co-occurring chronic diseases compared with patients without mental health disorders. They are also more likely to have frequent ED visits.
• Trends:
  • From 2007 to 2013, the overall rate of ED visits with a principal diagnosis related to mental health increased from 1,063.5 to 1,268.7 per 100,000 population.
• Groups With Disparities:
  • In all years, individuals in the highest income quartile were less likely than individuals in all other income groups to have an ED visit with a principal diagnosis related to mental health.
  • In 2013, the rate of ED visits with a principal diagnosis related to mental health was lowest for individuals in the West (1,031.1 per 100,000 population) and highest in the Northeast (1,650.3 per 100,000 population).
  • In 6 of 7 years, residents of micropolitan areas were more likely than residents of large fringe metropolitan areas (suburbs) to have an ED visit with a principal diagnosis related to mental health (data not shown).

Emergency Department Visits Related to Substance Abuse Only

Emergency department visits with a principal diagnosis of substance abuse only, by region and income, 2007-2013

Left Chart:

Right Chart:

Key: Q = quartile of median household income of the patient's ZIP code of residence.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, and HCUPnet query, 2007-2013.

• Importance:
  • In 2011, the Drug Abuse Warning Network estimated that about 2.5 million ED visits resulted from medical emergencies involving drug misuse or abuse. Of all drug misuse or abuse ED visits, about 1.25 million ED visits, or 50%, involved illicit drugs, about 1.24 million, or 50%, involved nonmedical use of pharmaceuticals, and about 0.61 million, or 25%, involved drugs combined with alcohol.
  • According to the Centers for Disease Control and Prevention, the United States is experiencing an epidemic of drug overdose deaths. Since 2000, the rate of deaths from drug overdoses has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids. The rate of drug overdose deaths increased significantly for both sexes, people ages 25-44 and 55 and over, non-Hispanic Whites, non-Hispanic Blacks, and residents of the Northeastern, Midwestern, and Southern regions (Rudd, et al., 2016).
• Trends:
  • From 2007 to 2013, the overall rate of ED visits with a principal diagnosis related to substance abuse increased from 437.7 to 577.7 per 100,000 population.
• Groups With Disparities:
  • In 2013, the rate of ED visits with a principal diagnosis of substance abuse was lowest for individuals in the South (430.5 per 100,000 population) and highest in the Northeast (1,105.5 per 100,000 population).
  • In all years, individuals in the highest income quartile were less likely than individuals in all other income groups to have an ED visit with a principal diagnosis related to substance abuse.

Emergency Department Visits Related to Dental Conditions

Emergency department visits with a principal diagnosis of dental conditions, by age, 2009-2013, and geographic location, 2010-2013

Left Chart:

Right Chart:

Key: MSA = metropolitan statistical area.
Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Emergency Department Sample, and HCUPnet query, 2009-2013.
Note: Data not available for 2009 for geographic location.

• Importance: Dental conditions such as dental caries, pulpal lesions, and gingival or periodontal conditions are treated routinely in dental office settings. When neglected, these minor localized infections can progress to form cellulitis or systemic infection and can even result in death. Evidence shows that care provided in hospital settings is less effective in managing oral health complaints and therefore may represent a highly inefficient use of limited hospital resources.
• Trends:
  • From 2009 to 2013, the overall rate of emergency department visits with a principal diagnosis related to dental conditions increased from 307.0 to 316.1 per 100,000 population.
• Groups With Disparities:
  • In 2013, the rate of ED visits with a principal diagnosis of dental conditions was lowest for individuals age 85 and over (45.0 per 100,000 population) and highest for individuals ages 18-44 (633.7 per 100,000 population).
  • In all years, residents of micropolitan and noncore areas were more likely than residents of large fringe metropolitan areas to have an ED visit with a principal diagnosis of dental conditions.

Emergency Department Visits for Asthma, Ages 18-39

Emergency department visits for asthma, ages 18-39, by hospital region and income, 2008-2013

Left Chart:

Right Chart:

Key: Q = quartile of median household income of the patient's ZIP code of residence.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.4, 2008-2013.
Note: Rates are age adjusted.

• Importance: Asthma exacerbations were responsible for approximately 2 million ED visits in 2012. ED visits for asthma exacerbation suggest a failure of prevention-oriented care since most asthma exacerbations are preventable with high-quality long-term management.
• Trends:
  • From 2008 to 2013, the overall rate of ED visits for asthma increased from 578.0 to 613.1 per 100,000 population.
• Groups With Disparities:
  • From 2008 to 2013, rates of ED visits for asthma were highest in the Northeast and lowest in the West. In 2013, the rate of ED visits for asthma in the Northeast was 914.8 per 100,000 population, followed by the Midwest (674.4 per 100,000 population), the South (577.9 per 100,000 population), and the West (400.7 per 100,000 population).
  • In all years, adults with the highest income were significantly less likely than all other income groups to have an ED visit for asthma.

Emergency Department Visits for Asthma, Ages 2-17

Emergency department visits for asthma, ages 2-17, by hospital region and income, 2008-2013

Left Chart:

Right Chart:

Key: Q = quartile of median household income of the patient's ZIP code of residence.
Source: Agency for Healthcare Research and Quality (AHRQ), Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.4, 2008-2013.

• Importance: Asthma exacerbations were responsible for approximately 2 million ED visits in 2012. ED visits for asthma exacerbation suggest a failure of prevention-oriented care since most asthma exacerbations are preventable with high-quality long-term management.
• Trends:
  • From 2008 to 2013, the overall rate of emergency department visits for asthma increased from 851.9 to 930.3 per 100,000 population.
• Groups With Disparities:
  • From 2008 to 2013, rates of ED visits for asthma were highest in the Northeast and lowest in the West. In 2013, the rate of ED visits for asthma in the Northeast was 1,297.6 per 100,000 population, followed by the South (922.8 per 100,000 population), the Midwest (868.8 per 100,000 population), and the West (752.5 per 100,000 population).
  • In all years, children in households in the highest income quartile were significantly less likely than all other income groups to have an ED visit for asthma.

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